Factors Influencing Utilization of Voluntary Counseling and Testing Service in Kasenyi Fishing Community in Uganda

Enhanced Oral Pre-exposure Prophylaxis (PrEP) Implementation for Ugandan Fisherfolk: Pilot Intervention Outcomes

Mobile populations such as fisherfolk show high HIV incidence and prevalence. We pilot-tested implementation strategies to enhance pre-exposure prophylaxis (PrEP) uptake and adherence in the context of healthcare outreach events in two mainland fisherfolk communities on Lake Victoria, Uganda from September 2021 to February 2022. The implementation strategies included PrEP adherence supporters (selected from PrEP users' social networks), community workshops (to address misconceptions and stigma, and empower PrEP advocacy), and check-in calls (including refill reminders). PrEP medical records data were collected from 6-months pre-intervention to 6-months post-intervention. Qualitative interviews with 20 PrEP users (10 who continued, 10 who discontinued), 9 adherence supporters, and 7 key partners (providers, community leaders) explored acceptability. Percentages of PrEP initiators (of those eligible) were significantly higher during the intervention (96.5%) than 6-months before the intervention (84.5%), p < 0.0001; percentages of PrEP users who persisted (i.e., possessed a refill) 6-months post-initiation (47.9% vs. 6.7%) and had at least 80% PrEP coverage (based on their medication possession ratio) from the initiation date to 6-months later (35.9% vs. 0%) were higher during versus pre-intervention, p < 0.0001. A comparison fisherfolk community with better healthcare access had lower uptake (78.3%; p < 0.0001) and persistence at 6-months (34.0%; p < 0.001), but higher coverage during the intervention period (70.4%; p < 0.0001). Qualitative data suggested the strategies promoted PrEP use through reduced stigma and misconceptions. The intervention bundle cost was $223.95, $172.98, and $94.66 for each additional person for PrEP initiation, persistence, and coverage, respectively. Enhanced community-based PrEP implementation that fosters a supportive community environment can improve PrEP use in mobile populations without easy access to healthcare. (NCT05084716).

HIV epidemic in fishing communities in Uganda: A scoping review

Background

Fishing communities in many Sub-Saharan African countries are a high-risk population group disproportionately affected by the HIV epidemic. In Uganda, literature on HIV in fishing communities has grown extensively since the first country’s documented case of HIV in a fishing community in 1985. The current study describes the status of the HIV burden, prevention, and treatment in Ugandan fishing communities.

Method

This scoping review was conducted based on the York Framework outlined by Arksey and O’Malley. We searched the PubMed, Embase, and Web of Science databases to identify relevant quantitative and qualitative studies on HIV incidence, HIV prevalence, HIV-related risk factors, HIV testing, antiretroviral therapy coverage and adherence, and interventions to improve treatment outcomes and reduce HIV risk factors.

Results & conclusion

We identified 52 papers and 2 reports. Thirty-four were quantitative, 17 qualitative, and 3 had a mixed-methods design. Eleven studies reported on the prevalence of HIV and 8 on HIV incidence; 9 studies documented factors associated with HIV incidence or HIV positive status; 10 studies reported on HIV testing coverage and/or associated factors; 7 reported on antiretroviral therapy coverage/adherence/outcomes; and 1 study reported on the impact of combination HIV interventions in fishing communities. This scoping review revealed a significant lack of evidence in terms of what works in HIV prevention and for improving adherence to ART, in contrast to the relatively large amount of evidence from observational quantitative and qualitative studies on HIV prevalence, incidence and related risk factors in Ugandan fishing communities. Intervention studies are urgently needed to fill the current evidence gaps in HIV prevention and ART adherence.

Efficacy of HIV interventions in African fishing communities: A systematic review and qualitative synthesis

OBJECTIVES

This systematic review aims to qualitatively synthesize existing evidence on the efficacy of HIV interventions in African fishing communities.

METHODS

Five databases (NCBI PubMed, EMBASE, Web of Science Core Collection, The Cochrane Library, and CABI Global Health Database) were searched in March 2019 for eligible studies. All peer-reviewed papers with a defined HIV intervention explicitly mentioning African fishing communities were included. Outcomes included any measure of the efficacy of HIV interventions.

RESULTS

Of 22,289 search results, data was extracted from 25 eligible studies that passed critical appraisal; seven involved HIV prevention, six HIV testing and counseling, three treatment, and nine combinations of more than one intervention. Findings include a high coverage of safe male circumcision (SMC) but low condom use among fisher folk, and a preference for PrEP over other HIV prevention services. Uptake of HIV testing and ART coverage are below levels required to reach UNAIDS 90-90-90 targets, and there is a high demand for ART and HIV self-testing kits.

CONCLUSIONS

Greater provision of services to combat HIV, specifically amongst fishing communities, is required; there is limited information on retaining fisher folk in care and achieving an undetectable viral load. Interventions tailored to individual fishing populations, offered in parallel to education or counseling services are likely to be most effective. Use of innovations, including mobile health and medical drones, could assist these hard-to-reach populations. Our findings will inform future HIV service provision in fishing communities.

Feasibility and acceptability of a pilot, peer-led HIV self-testing intervention in a hyperendemic fishing community in rural Uganda

Background

Novel interventions are needed to reach young people and adult men with HIV services given the low HIV testing rates in these population sub-groups. We assessed the feasibility and acceptability of a peer-led oral HIV self-testing (HIVST) intervention in Kasensero, a hyperendemic fishing community (HIV prevalence: 37–41%) in Rakai, Uganda.

Methods

This study was conducted among young people (15–24 years) and adult men (25+ years) between May and August 2019. The study entailed distribution of HIVST kits by trained “peer-leaders,” who were selected from existing social networks and trained in HIVST distribution processes. Peer-leaders received up to 10 kits to distribute to eligible social network members (i.e. aged 15–24 years if young people or 25+ years if adult man, not tested in the past 3 months, and HIV-negative or of unknown HIV status at enrolment). The intervention was evaluated against the feasibility benchmark of 70% of peer-leaders distributing up to 70% of the kits that they received; and the acceptability benchmark of >80% of the respondents self-testing for HIV.

Results

Of 298 enrolled into the study at baseline, 56.4% (n = 168) were young people (15–24 years) and 43.6% (n = 130) were adult males (25+ years). Peer-leaders received 298 kits and distributed 296 (99.3%) kits to their social network members. Of the 282 interviewed at follow-up, 98.2% (n = 277) reported that they used the HIVST kits. HIV prevalence was 7.4% (n = 21). Of the 57.1% (n = 12) first-time HIV-positives, 100% sought confirmatory HIV testing and nine of the ten (90%) respondents who were confirmed as HIV-positive were linked to HIV care within 1 week of HIV diagnosis.

Conclusion

Our findings show that a social network-based, peer-led HIVST intervention in a hyperendemic fishing community is highly feasible and acceptable, and achieves high linkage to HIV care among newly diagnosed HIV-positive individuals.

Acceptability of children's testing for HIV infection during routine care activities in the Pediatrics Department of Sourô Sanou Teaching Hospital in Bobo-Dioulasso (Burkina Faso)

BACKGROUND

In order to contribute to the fight against the pediatric HIV infection, we have assessed, through a study in which we have systematically proposed to carry out children's testing, the rate of acceptability and the feasibility of children's HIV testing during the routine activities of the department. We have also analyzed the reasons for the acceptability or the refusal of the child's HIV testing by the accompanying person.

METHODS

The study took place from May to September 2015 including all the parents/legal guardians of any child aged 0 to 14 years coming for a consultation or who was hospitalized in the Pediatric Department of Souro Sanou Teaching Hospital. Counseling sessions conducted by community health workers focused on informing and proposing the principle of child testing. After obtaining the verbal and informed consent of the accompanying person, the first test was performed with Determine® by a hospital health worker. A second SD Bioline®/ImmunoCombII® test was performed if the first test was positive. With children aged less than 18 months, after a positive antibody test, we resorted to PCR for confirmation.

RESULTS

A total of 848 accompanying persons, 568 of whom were female, underwent a pre-test interview during which the HIV test was offered to them. The mean age of accompanying persons was 30 (25.5 to 38) years; 747 accompanying persons (88.1%) accepted the testing of their child. We have found an influence of the accompanying person's religion (P=0.02) and the type of accompanying person on the acceptability of children's testing. Mothers were more willing to accept the test compared to other accompanying persons (P=0.002). The main reason for refusing the child's testing was the absence of one of the child's parents, mainly the father whose opinion was needed. The test was positive for HIV1 in 10 children.

CONCLUSION

In health centers, getting the informed consent from parents to test their children is a big challenge. However, our study shows that this is possible, through the high rate of acceptability obtained.

Barriers to Linkage to HIV Care in Ugandan Fisherfolk Communities: A Qualitative Analysis

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 healthcare. 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.

Understanding the socio-structural context of high HIV transmission in kasensero fishing community, South Western Uganda

BACKGROUND

In Kasensero fishing community, home of the first recorded case of HIV in Uganda, HIV transmission remains high with an incidence of 4.3 and 3.1 per 100 person-years in women and men, respectively, and an HIV prevalence of 44 %, reaching up to 74 % among female sex workers. We explored the social contextual factors for the high HIV transmission at Kasensero to inform future policy and preventive interventions.

METHODS

We conducted 20 in-depth interviews, including both HIV positive and HIV negative respondents, and 12 focus-group discussions involving a total of 92 respondents from the Kasensero fishing community from April-September 2014. Content analysis was performed to identify recurrent themes.

RESULTS

Our findings suggest that the high HIV transmission in Kasensero is a complex function of eight themes including; positive/negative attitudes about HIV and combination HIV prevention such as the demand for services versus ART/circumcision disinhibition; HIV depository; Multiple partners; Frequent unprotected sex; Clothing; Parental behaviors; Pressure within the sex industry; and Cross generational sex.

CONCLUSIONS

The current combination HIV prevention services by the RHSP need to be enhanced with more government involvement including ensuring sustainable supply of ART and circumcision services since they are reportedly highly demanded. Community involvement through the engagement of popular peers could also help in the campaign to change the HIV predisposing culture, misconceptions and risky social norms of the population. Social Context HIV Transmission Fishing Community.

HIV-related characteristics among female partners of injecting drug users in Kelantan, Malaysia: a descriptive study

Kelantan, a northeastern state in Peninsular Malaysia, is one of the states that has been acutely hit by injecting drug user (IDU)-driven HIV epidemic, in addition to having a high number of infected women in Malaysia. This cross-sectional study describes the socio-demographic characteristics, HIV risk factors, risk perception, and adoption of preventive behaviors among female partners of IDUs in Kelantan. Out of 101 women, the majority of them are from low socioeconomic background and have no other risk factors besides heterosexual HIV transmission from their male IDU partners. Although 45.5% have not been tested for HIV and more than half (53.5%) of them did not use condoms during sexual intercourse, only 44.6% of the women perceived themselves to be at risk of being infected with HIV. Most of the women (86.1%) were willing to undergo voluntary counseling and testing (VCT). Female partners of IDUs continue to be vulnerable to HIV due to having sexual contact with IDUs, and also due to their socioeconomic position in the community. To prevent HIV transmission among female partners of IDUs, consolidating HIV prevention efforts from multiple approaches is needed.

Accuracy of un-supervised versus provider-supervised self-administered HIV testing in Uganda: A randomized implementation trial

Unsupervised HIV self-testing (HST) has potential to increase knowledge of HIV status; however, its accuracy is unknown. To estimate the accuracy of unsupervised HST in field settings in Uganda, we performed a non-blinded, randomized controlled, non-inferiority trial of unsupervised compared with supervised HST among selected high HIV risk fisherfolk (22.1 % HIV Prevalence) in three fishing villages in Uganda between July and September 2013. The study enrolled 246 participants and randomized them in a 1:1 ratio to unsupervised HST or provider-supervised HST. In an intent-to-treat analysis, the HST sensitivity was 90 % in the unsupervised arm and 100 % among the provider-supervised, yielding a difference 0f -10 % (90 % CI -21, 1 %); non-inferiority was not shown. In a per protocol analysis, the difference in sensitivity was -5.6 % (90 % CI -14.4, 3.3 %) and did show non-inferiority. We conclude that unsupervised HST is feasible in rural Africa and may be non-inferior to provider-supervised HST.

Masculinity, social context and HIV testing: an ethnographic study of men in Busia district, rural eastern Uganda

Background

Uptake of HIV testing by men remains low in high prevalence settings in many parts of Africa. By focusing on masculinity, this study explores the social context and relations that shape men’s access to HIV testing in Mam-Kiror, Busia district, rural eastern Uganda.

Methods

From 2009–2010 in-depth interviews were undertaken with 26 men: nine being treated for HIV, eight who had tested but dropped out of treatment, six not tested but who suspected HIV infection and three with other health problems unrelated to HIV. These data were complemented by participant observation. Thematic analysis was undertaken.

Results

There were two main categories of masculinity in Mam-Kiror, one based on ‘reputation’ and the other on ‘respectability’, although some of their ideals overlapped. The different forms of masculine esteem led to different motives for HIV testing. Men positioned HIV testing as a social process understood within the social context and relationships men engaged in rather than an entirely self-determined enterprise. Wives’ inferior power meant that they had less influence on men’s testing compared to friends and work colleagues who discussed frankly HIV risk and testing. Couple testing exposed men’s extra-marital relationships, threatening masculine esteem. The fear to undermine opportunities for sex in the context of competition for partners was a barrier to testing by men. The construction of men as resilient meant that they delayed to admit to problems and seek testing. However, the respectable masculine ideal to fulfil responsibilities and obligations to family was a strong motivator to seeking an HIV test and treatment by men.

Conclusion

The two main forms of masculine ideals prevailing in Mam-Kiror in Busia led men to have different motives for HIV testing. Reputational masculinity was largely inconsistent with the requirements of couple testing, community outreach testing and the organisation of testing services, discouraging men from testing. Conversely, concern to perform one’s family roles as a respectable man meant accessing treatment to extend one’s life, which encouraged men to test. HIV support agencies should reflect on how various testing options might marginalise men from seeking testing services and address the barriers that hinder access.

Community influences on married men's uptake of HIV testing in eight African countries

Despite efforts to increase HIV testing in the African region, the proportion of men who report ever having been tested for HIV remains low. Research has focused on individual level determinants of women's testing however little is known about factors associated with men's testing behavior. This analysis investigates community influences on HIV testing among men ages 15-54, using Demographic and Health Survey (DHS) data from Chad, Ghana, Malawi, Nigeria, Tanzania, Uganda, Zambia, and Zimbabwe. Multilevel models were fitted in each country for the outcome of ever receiving an HIV test. After controlling for individual and household level factors, community level factors of demographics, economics, and behavior and knowledge remain significantly associated with HIV testing among men. The results of this analysis highlight the need to recognize the impact of community influences on men's HIV test seeking behavior, and to harness these community factors in the design of programs aimed at encouraging the uptake of HIV testing among men in Africa.

Predictors of recent HIV testing among male street laborers in urban Vietnam

This study assessed the prevalence of and factors associated with HIV testing among male street laborers. In a cross-sectional survey, social mapping was done to recruit and interview 450 men aged 18-59 years in Hanoi. Although many of these men engaged in multiple risk behaviors for HIV, only 19.8 percent had been tested for HIV. A modified theoretical model provided better fit than the conventional Information-Motivation-Behavioral Skills model, as it explained much more variance in HIV testing. This model included three Information-Motivation-Behavioral components and four additional factors, namely, the origin of residence, sexual orientation, the number of sexual partners, and the status of condom use.

Intention to voluntary HIV counseling and testing (VCT) among health professionals in Jimma zone, Ethiopia: the theory of planned behavior (TPB) perspective

Background

Voluntary HIV Counseling and Testing (VCT) forms one of the cornerstones of HIV prevention strategies. It is imperative to understand HIV testing correlates and their theoretical underpinnings in order to promote VCT uptake. The aim of this study was to predict the intention to VCT and associated factors among health professionals in Jimma zone, Ethiopia using the theory of planned behavior.

Methods

An institution based cross-sectional quantitative study among a sample of 336 health professionals in 12 selected districts of Jimma, Ethiopia was conducted in 2012. The constructs and principles of the theory of planned behavior (TPB) were measured. Data were collected using structured questionnaire on self administered basis. A multivariable linear regression model was used to predict the role of independent variables/TPB constructs on the intention to use VCT using SPSS version 16.0.

Results

The components of TPB independently explained the variance in intention to VCT by 30.3%. Both components of TPB and socio-demographic characteristic in the final model explained 32.7% of variance in the intention to use VCT services. Significant proportions (33.0%) of the respondents have never been tested for HIV. The respective indirect components of the TPB predicted the direct components. The strongest predictors of intention to VCT were subjective norm (β=0.39, p<0.001) and attitude (β= 0.19, p<0.001) whereas, none of the socio-demographic variables were significantly predicted the intention to use VCT. Past VCT experience did not have significant statistical association with VCT use intention.

Conclusions

Behavioral intention to use VCT was a function of attitude and perceived social pressure. Demographic related social determinants were not barriers for VCT use intention. Most health workers test their blood by themselves. Strategies to empower health professionals on social pressure resistance and programs targeted at changing negative attitude on VCT use can enhance intention of health professionals to use VCT.

Testing experiences of HIV positive refugees in Nakivale Refugee Settlement in Uganda: informing interventions to encourage priority shifting

Background

Recent initiatives by international health and humanitarian aid organizations have focused increased attention on making HIV testing services more widely available to vulnerable populations. To realize potential health benefits from new services, they must be utilized. This research addresses the question of how utilization of testing services might be encouraged and increased for refugees displaced by conflict, to make better use of existing resources.

Methods

Open-ended interviews were conducted with HIV-infected refugees (N=73) who had tested for HIV and with HIV clinic staff (N=4) in Nakivale Refugee Settlement in southwest Uganda. Interviews focused on accessibility of HIV/AIDS-related testing and care and perspectives on how to improve utilization of testing services. Data collection took place at the Nakivale HIV/AIDS Clinic from March to July of 2011. An inductive approach to data analysis was used to identify factors related to utilization.

Results

In general, interviewees report focusing daily effort on tasks aimed at meeting survival needs. HIV testing is not prioritized over these responsibilities. Under some circumstances, however, HIV testing occurs. This happens when: (a) circumstances realign to trigger a temporary shift in priorities away from daily survival-related tasks; (b) survival needs are temporarily met; and/or (c) conditions shift to alleviate barriers to HIV testing.

Conclusion

HIV testing services provided for refugees must be not just available, but also utilized. Understanding what makes HIV testing possible for refugees who have tested can inform interventions to increase testing in this population. Intervening by encouraging priority shifts toward HIV testing, by helping ensure survival needs are met, and by eliminating barriers to testing, may result in refugees making better use of existing testing services.

Factors associated with history of HIV testing among pregnant women and their partners in Cameroon: baseline data from a Behavioral Intervention Trial (ANRS 12127 Prenahtest)

BACKGROUND

We investigated HIV testing practices at baseline among pregnant women and their partners within a multicountry randomized trial aiming to evaluate the effect of enhanced prenatal posttest HIV counseling on men's involvement.

METHODS

In Yaoundé, Cameroon, 484 pregnant women with stable partners were recruited on their first antenatal care visit. We analyzed the coverage of previous HIV testing among women and their partners and looked for the factors associated with previous HIV testing, using multivariable logistic regression.

RESULTS

Among 476 pregnant women who completed the baseline questionnaire, 408 (85.7%) reported having been tested for HIV already once in their life, 48.3% of them during a previous pregnancy. Women previously tested for HIV were more likely to be in a stable relationship for >5 years than those never tested (P < 0.001). In multivariable analysis, tested women were more likely to be aged between 25 and 30 years compared with women <20 years [odds ratio (OR) 5.5, 95% confidence interval (CI): 1.4 to 22.1], to be able to say whether they felt at risk for HIV infection (OR 2.1, CI: 1.1 to 3.9), and to have ever discussed about HIV with their partner (OR 2.7, CI: 1.1 to 6.4). Most women (85.1%) reported that their partner had already been tested for HIV. Reasons for partner HIV testing were related to self-motivation (30.0%) and clinical symptoms (12.7%).

CONCLUSIONS

Strategies aiming at improving knowledge and couple communication about HIV risks need to be considered to address the remaining barriers to HIV testing and contribute to a couple approach to HIV prevention.