Search

Introduction: Heterosexual couples are at high risk for HIV acquisition in sub-Saharan Africa, and HIV self-testing (HST) is an additional approach to expand access to HIV testing services. However, it is not well known how gender equality is associated with HST.Methods: We used intervention-arm data from a cluster-randomised controlled HST intervention trial (N = 1 618) conducted in Uganda to determine the association between attitudes towards intimate partner violence (IPV), decision-making power and male partner’s uptake of HST among heterosexual couples expecting a child in south-central Uganda. The original study question was to assess the impact of providing pregnant women with HST kits to improve male partner’s HIV testing rates. For this analysis, the primary exposures were gender equality (measured by male partner’s and female partner’s attitudes towards IPV and the female partner’s household decision-making power), and the primary outcome was the male partner’s uptake of HST. Multivariate logistic regression was used for analysis.Results: We found that male partner HST uptake did not vary depending on male partner’s attitudes towards IPV or decision-making power; however, male partner HST uptake did depend on the female partner’s attitude towards IPV, with 1.76 times more testing (95% CI 1.06–2.92) in couples where the woman had “medium” versus “high” acceptance of IPV, and 1.82 times more testing (95% CI 1.08–3.08) in couples where the woman had “low” versus “high” acceptance of IPV.Conclusions: This study shows the importance of appropriate negative attitudes by women to IPV in increasing male partner’s HST uptake to integrate HST into national health care policies.

Men’s engagement in the HIV care continuum may be negatively affected by adherence to inequitable gender norms, which may be exacerbated by HIV stigma. This cross-sectional study with 300 male fisherfolk in Uganda examined the independent and interacting effects of inequitable gender norm endorsement and HIV stigma on men’s missed HIV care appointments and missed antiretroviral (ARV) doses. Greater gender inequitable norm endorsement was associated with increased odds of missed HIV clinic visits (Adjusted Odds Ratio [AOR)]: 1.44, 95% CI: 1.16–1.78) and a statistically significant interaction between internalized HIV stigma and inequitable gender norms on missed ARV doses was identified (AOR: 5.32, 95% CI: 2.60–10.86). Adherence to traditional gender norms reduces men’s HIV appointment attendance, and among men with high internalized stigma, increases the likelihood of poor treatment adherence. These findings point to the need for HIV interventions that reconfigure harmful gender norms with a focus on stigma reduction.

Introduction: Understanding and following HIV self-testing (HIVST) instructions is a critical step in the use of HIVST kits. We analyzed data on pregnant women and their partners’ self-assessment on the usability of kits delivered by their pregnant women. Methods: Quantitative data were collected on 399 pregnant women and 238 male partners enrolled in the intervention arm of a large cluster-randomized HIVST trial. Each pregnant woman received HIVST demonstrations, detailed pictorial instructions on how to use OraQuick HIVST kits, and two kits; for herself and her male partner. Follow-up was at one month (baseline for male partners) and 3 months. Descriptive statistics were conducted to compare understanding and following of HIVST instructions by age and education level. Results: The proportion of those who understood HIVST instructions was almost the same (98%) for women and their partners, although partners (26.5%) were nearly twice as likely than women (16.0%) to report needing pretest counseling (Odds ratio [OR] = 1.9, 95% CI: 1.27–2.79). Partners’ understanding of the HIVST instructions did not vary by education level, but 4.4% of women with primary education reported difficulty in understanding HIVST instructions compared with 0.5% and 0% of those with secondary and university education, respectively ( p = 0.05). However, 5.6% of women aged 30–68 years and 3.3% of partners aged 20–24 years found it more difficult to understand the HIVST instructions. Conclusion: Both pregnant women and their male partners were correctly able to perform an HIVST without or (with minimal) support suggesting that this mode of delivery will help the national program reach more men. Because more male partners than women required HIVST pretest counseling support, male-targeted HIVST promotional messages may be needed to increase men's self-efficacy to perform HIVST unsupported.

BACKGROUND In Uganda, HIV testing rates are approximately 90% among women in antenatal care, with male rates much lower. The World Health Organization has recommended HIV self-testing (HIVST), and one promising model is for women in antenatal care to deliver HIVST kits to their male partners. We investigated the impact of this model on male partner testing rates. SETTING Three high-volume antenatal clinics in central Uganda. METHODS We implemented a cluster-randomized controlled trial comparing standard of care to intervention, with the primary outcome of self-reported male partner HIV testing. Women and male partners were followed at 1 and 3 months. We used unadjusted analyses and log-linear models with an intent-to-treat approach accounting for clustering. RESULTS Study coordinators randomized 1514 women (777 intervention and 737 control). Baseline characteristics were balanced across arms with mean age (SD) of 25.2 (5.5) years and >44% with secondary education or higher. More male partners tested for HIV in intervention [576/746 (77.2%)] versus control [264/709 (37.2%)], P < 0.01. We identified 34 HIV-positive men in intervention versus 10 in control, with 6/26 (23%) and 4/6 (67%), respectively, reporting linking to care. CONCLUSIONS Our results demonstrate an enormous increase in self-reported partner HIV testing when HIVST is available at home. However, men testing positive through HIVST appeared less likely to link to care than men testing positive at a clinic. These results highlight the potential of HIVST in increasing HIV testing rates, while underscoring the importance of developing effective approaches to maximizing linkage to care among those testing positive through HIVST.

Background: HIV is hyperendemic among fisherfolk in Sub-Saharan Africa, especially around Lake Victoria, Uganda. Purpose/Research Design: We conducted cross-sectional semi-structured interviews about oral pre-exposure prophylaxis (PrEP) implementation with 35 Ugandan fisherfolk (15 women, 20 men) and 10 key stakeholders (healthcare providers, policymakers, community leaders). We used a directed content analysis approach based on implementation science and social marketing frameworks. Results: Participants showed high acceptability for PrEP. Anticipated barriers among fisherfolk included stigma (due to similar medications/packaging as HIV treatment); misconceptions; mobility, competing needs, poverty, and partner conflict. Anticipated provider barriers included insufficient staffing and travel support. Recommendations included: change PrEP packaging; integrate PrEP with other services; decrease PrEP refill frequency; give transportation resources to providers; train more healthcare workers to provide PrEP to fisherfolk; and use positively framed messages to promote PrEP. Conclusions: Results can inform policymakers and healthcare organizations on how to overcome barriers to PrEP scale-up in most at-risk populations with poor healthcare access.

HIV testing rates remain stubbornly low among men – a crucial target population for reaching the ambitious global and regional goals of the HIV programme. In an era of declining donor funding, identifying cost-effective strategies to increase testing rates amongst men remains paramount. Antenatal care is an effective entry-point for the delivery of HIV testing services for women, and partner testing presents an important opportunity to reach their male partners. We present the results of a discrete choice experiment in Uganda, examining preferences among 824 pregnant women and 896 male partners regarding service delivery characteristics of HIV testing. Both men and women preferred nurse administered testing to self-testing (OR = 0.835; p < 0.001), oral testing over a finger-prick test (OR = 1.176; p < 0.001) and testing with a partner over testing alone (OR = 1.230; p < 0.001). Men had a preference for testing at home compared to testing at a clinic (OR = 1.099; p = 0.024), but women were indifferent regarding the testing location. The cost of testing had the biggest effect on preferences. Free testing was preferred over a cost of US$2.90 (OR = 0.781; p < 0.001) or US$2.00 (OR = 0.670; p < 0.001). Offering an incentive of US$3.40 increased men’s preferences compared to a free test (OR = 1.168; p < 0.001), although this did not affect women’s preferences. Partner testing linked to antenatal care is a potential strategy to increase testing coverage among men, particularly given the preference for partner testing – provided costs to clients remain low. Future cost-effectiveness evaluations should investigate the economic impact of reaching men using these strategies.Keywords: East Africa, randomized controlled trial, couples testing

This study explored the intersection of masculinity and HIV care engagement among fishermen and other male fisherfolk on antiretroviral therapy (ART) in Wakiso District, Uganda. We conducted 30 in-depth interviews with men on ART recruited from HIV treatment sites and used a thematic analysis approach to analysis. Since HIV diagnosis and ART initiation, men had adopted masculine identities more conducive with HIV care engagement. The masculine roles of worker and provider, husband and sexual partner, and the appearance of physical strength were compromised by HIV, but restored by ART’s positive effects on health. Peers also emerged as a facilitator to HIV care, with men supporting each other to seek testing and treatment. However, structural and occupational barriers to HIV care associated with the masculine role of worker remained a barrier to care engagement. Findings suggest emphasising the benefits of ART in bolstering men’s ability to fulfil the roles important to them may improve the effectiveness of HIV testing and treatment messaging for men. Differentiated care models that address structural-level barriers to care, and community-level gender transformative programming to help fishermen engage in HIV care, may be beneficial.

Background According to the user instructions from the manufacturer of OraQuick HIV self-test (HIVST) kits, individuals whose kits show one red band should be considered to be HIV-negative, no matter how weak the band is. However, recent reports show potential for a second false weak band after storage, thereby creating confusion in the interpretation of results. In this study, we re-tested individuals whose results were initially non-reactive but changed to weak reactive results to determine their true HIV status. Methods This study was nested within a large, cluster-randomized HIVST trial implemented among pregnant women attending antenatal care and their male partners in central Uganda between July 2016 and February 2017. Ninety-five initially HIV-negative respondents were enrolled into this study, including 52 whose kits developed a second weak band while in storage and 43 whose kits were interpreted as HIV-positive by interviewers at the next follow-up interview. Respondents were invited to return for repeat HIVST which was performed under the observation of a trained nurse counsellor. After HIVST, respondents underwent blood-based rapid HIV testing as per the national HIV testing algorithm (Determine (Abbot Laboratories), STAT-PAK (Chembio Diagnostic Systems Inc.) and Unigold (Trinity Biotech plc.) and dry blood spots were obtained for DNA/PCR testing. DNA/PCR was considered as the gold-standard HIV testing method. Results After repeat HIVST, 90 (94.7%) tested HIV-negative; 2 (2.1%) tested HIV-positive; and 3 (3.2%) had missing HIV test results. When respondents were subjected to blood-based rapid HIV testing, 97.9% (93/95) tested HIV-negative while 2.1% (2/95) tested HIV-positive. Finally, when the respondents were subjected to DNA/PCR, 99% (94/95) tested HIV-negative while 1.1% (1/95) tested HIV-positive. Conclusions Nearly all initially HIV-negative individuals whose HIVST kits developed a second weak band while in storage or were interpreted as HIV-positive by interviewers were found to be HIV-negative after confirmatory DNA/PCR HIV testing. These findings suggest a need for HIV-negative individuals whose HIVST results change to false positive while under storage or under other sub-optimal conditions to be provided with an option for repeat testing to determine their true HIV status.

HIV fatalism, or the belief that HIV acquisition and mortality is out of one's control, is thought to contribute to HIV risk in fishing populations in East Africa. The objective of this cross-sectional study was to investigate the association between fatalism and sexual risk behaviours (unprotected sex, engagement in transactional sex), beyond the influence of other known HIV risk factors (e.g. food insecurity, mobility), and identify demographic, psychosocial, and structural correlates of HIV fatalism. Ninety-one men and women living in fishing villages on two islands in Lake Victoria, Uganda completed an interviewer-administered questionnaire after testing HIV-positive during home or community-based HIV testing between May and July 2015. Multivariate logistic regression was used to test the association between HIV fatalism and transactional sex and multivariate linear regression was used to identify demographic, psychosocial, and structural correlates of HIV fatalism. HIV fatalism was significantly associated with a greater likelihood of transactional sex (AOR = 3.07, 95% CI = 1.02–9.23, p = 0.04), and structural barriers to HIV care (e.g. distance to clinic) were significantly associated with HIV fatalism (β = 0.26, SE = 0.12, p = 0.04). Our findings highlight HIV fatalism as a contributor to transactional sex in Ugandan fishing communities, and as a product of broader social and contextual factors, suggesting the potential need for structural HIV interventions in this setting.

This cross-sectional study assessed determinants of HIV clinic appointment attendance and antiretroviral treatment (ART) adherence among 300 male fisherfolk on ART in Wakiso District, Uganda. Multi-level factors associated with missed HIV clinic visits included those at the individual (age, AOR = 0.98, 95% CI 0.97–0.99), interpersonal (being single/separated from partner, AOR: 1.25, 95% CI 1.01–1.54), normative (anticipated HIV stigma, AOR: 1.55, 95% CI 1.05–2.29) and physical/built environment-level (travel time to the HIV clinic, AOR: 1.11, 95% CI 1.02–1.20; structural-barriers to ART adherence, AOR: 1.27, 95% CI 1.04–1.56; accessing care on a landing site vs. an island, AOR: 1.35, 95% CI 1.08–1.67). Factors associated with ART non-adherence included those at the individual (age, β: − 0.01, η(2) = 0.03; monthly income, β: − 0.01, η(2) = 0.02) and normative levels (anticipated HIV stigma, β: 0.10, η(2) = 0.02; enacted HIV stigma, β: 0.11, η(2) = 0.02). Differentiated models of HIV care that integrate stigma reduction and social support, and reduce the number of clinic visits needed, should be explored in this setting to reduce multi-level barriers to accessing HIV care and ART adherence.

Ugandan fishing communities are dually burdened with high rates of HIV and alcohol use. This qualitative study explores context and motivation of alcohol consumption, and alcohol's effect on antiretroviral treatment (ART) adherence, among male fisherfolk living with HIV in Wakiso District, Uganda. We conducted in-depth semi-structured interviews with 30 men in HIV care and on ART, and used a thematic analysis approach for analysis. Alcohol use was identified as a major barrier to ART adherence through cognitive impairment and the intentional skipping of doses when drinking. Men reportedly reduced their drinking since HIV diagnosis - motivated by counseling received from providers and a newfound desire to live a healthy lifestyle. However, social, occupational, and stress-related influences that make alcohol reduction difficult were identified. Our findings suggest alcohol use may pose a challenge to ART adherence for fishermen living with HIV - and has implications for the tailoring of screening and brief intervention for alcohol reduction in HIV care for this population.

We compared two community-based HIV testing models among fisherfolk in Lake Victoria, Uganda. From May to July 2015, 1364 fisherfolk residents of one island were offered (and 822 received) home-based testing, and 344 fisherfolk on another island were offered testing during eight community mobilization events (outreach event-based testing). Of 207 home-based testing clients identified as HIV-positive (15% of residents), 82 were newly diagnosed, of whom 31 (38%) linked to care within 3 months. Of 41 who screened positive during event-based testing (12% of those tested), 33 were newly diagnosed, of whom 24 (75%) linked to care within 3 months. Testing costs per capita were similar for home-based ($45.09) and event-based testing ($46.99). Compared to event-based testing, home-based testing uncovered a higher number of new HIV cases but was associated with lower linkage to care. Novel community-based test-and-treat programs are needed to ensure timely linkage to care for newly diagnosed fisherfolk.

OBJECTIVES/SPECIFIC AIMS: We investigated the association between relationship power imbalance (which can have a negative impact on HIV prevention) and male partner HIV testing, using baseline data from a HIV self-testing trial in 3 antenatal clinics in central Uganda. METHODS/STUDY POPULATION: Pregnant women with HIV-male partners were recruited and randomized by day into standard of care or intervention (HIV self-testing kits). Analyses were performed in SAS 9.4, with χ2 tests and ppp=0.02, 12.4% of women whose partners tested showed a sometimes difficult relationship vs. 5.7% of women whose partners did not test). Among women 26+, decision making for family visits differed by partner testing (overall p=0.005, 52.9% of women made joint decisions with partners who tested vs. 36.5% whose partners did not test). DISCUSSION/SIGNIFICANCE OF IMPACT: Higher relationship power balance was associated with higher HIV testing among male partners when measured by contribution to expenses and decision making for family visits, but not relationship status. Relationship power balance should be considered when counseling women and men to increase HIV testing.

Steve Kanters,1,3 Margaret Nansubuga,2 Daniel Mwehire,2 Mary Odiit,2 Margaret Kasirye,2 William Musoke,2 Eric Druyts,3 Sanni Yaya,3 Anna Funk,3 Nathan Ford,4,5 Edward J Mills3,61Faculty of Health Science, Simon Fraser University, Burnaby, BC, Canada, 2Mildmay Uganda, Kampala, Uganda; 3Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada; 4Médecins Sans Frontières, Geneva, Switzerland; 5Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa; 6Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USABackground: We aimed to assess the relationship between gender and survival among adult patients newly enrolled on antiretroviral therapy (ART) in Uganda. We also specifically examined the role of antenatal services in favoring women's access to HIV care.Methods: From an observational cohort study, we assessed survival and used logistic regression and differences in means to compare men and women who did not access care through antenatal services. Differences were assessed on measures of disease progression (WHO stage and CD4 count) and demographic (age, marital status, and education), behavioral (sexual activity, disclosure to partner, and testing), and clinical variables (hepatitis B and C, syphilis, malaria, and anemia). A mediational analysis that considered gender as the initial variable, time to death as the outcome, initial CD4 count as the mediator, and age as a covariate was performed using an accelerated failure time model with a Weibull distribution.Results: Between 2004 and 2011, a total of 4775 patients initiated ART, and after exclusions 4537 (93.2%) were included in analysis. Men initiating ART were more likely to have a WHO disease stage III or IV (odds ratio: 1.46, 95% confidence interval [CI]: 1.29–1.66), and lower CD4 cell counts compared to women (median baseline CD4 124 cells/mm3, interquartile range [IQR]: 43–205 versus 147 cells/mm3, IQR: 68–212, P-value < 0.0001). Men were at an increased risk of death compared to women (hazard ratio: 1.38, 95% CI: 1.03–1.83). Baseline CD4 cell counts accounted for 43% of the increased risk of death in men (95% CI: 22%–113%). Access to care via antenatal services did not explain differences in outcomes.Conclusion: In this cohort there is a marked increase in risk of mortality for men and approximately half of it can be attributed to their later engagement in care. More effort is required to engage men in care in a timely manner.Keywords: HIV, antiretroviral therapy, gender, Uganda, antenatal care, mortality

Among Ugandan fisherfolk, HIV prevalence (with estimates ranging from 15 to 40 %) is higher than in the general population (about 7 %), potentially due to high-risk behaviors and low access to HIV testing and health-care. We conducted semi-structured interviews on barriers to linkage to care with 10 key stakeholders and 25 fisherfolk within 1–2 months of their testing HIV-positive at clinic outreach events in Ugandan Lake Victoria communities. Interviews were recorded, transcribed, translated, and coded using grounded theory methods. Participants cited low healthcare access and quality of care, mobility, competing needs for work during clinic hours, stigma, and low social support as barriers. Over 10 % of clients screened positive for HIV at outreach events, and only half accessed care. Linkage to care issues may begin with the failure to attract high-risk fisherfolk to testing. New models of HIV testing and treatment delivery are needed to reach fisherfolk.

This case report describes an HIV-positive patient with recurrent tuberculosis in Uganda. After several failed courses of treatment, the patient was diagnosed with multi-drug resistant tuberculosis (MDR-TB). As adequate in-patient facilities were unavailable, we advised the patient to remain at home, and he received treatment at home via his family and a community nurse. The patient had a successful clearance of tuberculosis. This strategy of home-based care represents an important opportunity for treatment of patients in East Africa, where human resource constraints and inadequate hospital facilities exist for complex patients at high risk of infection to others.