Increasing HIV-1 prevalence among pregnant women living in rural areas of the Gulu district (North Uganda)

Cango Lyec (Healing the Elephant): Gender Differences in HIV Infection in Post-conflict Northern Uganda

Background:

As previously encamped resettle, potential for rapid HIV transmission in post-conflict Northern Uganda is concerning. Women in particular may be experiencing heightened vulnerability resulting from war-related sexual violence.

Setting:

Cango Lyec (Healing the Elephant) Project is a cohort involving conflict-affected people in 3 districts in Northern Uganda.

Methods:

Eight randomly selected communities were mapped, and a census was conducted. Participants aged 13–49 years completed questionnaires in Luo on war-related experiences, mental health, sexual vulnerabilities, and sociodemographics. Blood samples were tested for HIV and syphilis. Baseline data from all sexually active participants was used to determine gender differences in HIV prevalence. Multivariate modeling determined correlates of HIV by gender.

Results:

Among 2008 participants, HIV prevalence was higher among women [17.2; 95% confidence interval (CI): 14.7 to 19.7] compared to men (10.6; 95% CI: 8.0 to 13.2, <0.001). Among women, correlates of HIV included: war-related sexual assault [adjusted odds ratio (AOR): 1.95; 95% CI: 1.16 to 3.26]; probable depression (AOR: 2.22; 95% CI: 1.46 to 3.37); probable post-traumatic stress disorder (AOR: 2.03; 95% CI: 1.45 to 2.84); experiencing ≥12 traumatic events (AOR: 2.04; 95% CI: 1.31 to 3.18); suicide ideation (AOR: 1.67; 95% CI: 1.22 to 2.28); living in a female-headed household (AOR: 2.76; 95% CI: 1.70 to 4.49); first sexual partner ≥10 years older (AOR: 1.69; 95% CI: 1.07 to 2.67); sex for exchange (AOR: 5.51; 95% CI: 1.76 to 17.31); having 2 (AOR: 2.54; 95% CI: 1.23 to 5.23) or 3+ (AOR: 4.65; 95% CI: 2.65 to 8.18) sexual partners; inconsistent condom use (AOR: 0.40; 95% CI: 0.29 to 0.57); genital ulcers (AOR: 3.08; 95% CI: 2.16 to 4.38); active syphilis (AOR: 4.33; 95% CI: 1.22 to 15.40); and ill health without medical care (AOR: 2.02; 95% CI: 1.22 to 3.34). Among men, correlates of HIV included no condom at sexual debut (AOR: 1.92; 95% CI: 1.30 to 2.83) and genital ulcers (AOR: 4.40; 95% CI: 1.35 to 14.40).

Conclusion:

Women are disproportionately impacted by HIV, trauma, and depression in this conflict-affected population. Trauma-informed HIV prevention and culturally safe mental health initiatives are urgently required.

HIV-1 seroprevalence among pregnant women in rural Uganda: a longitudinal study over fifteen years

INTRODUCTION

In order to determine the development of the prevalence of HIV infection in rural Western Uganda, data of epidemiological studies conducted in 2001 and 2007 were compared to study data from 1993.

METHODS

In 2001 (n = 466) and in 2007 (n = 486), one group each of clinically healthy pregnant women of a local prenatal care department were enrolled in the study and anonymously screened for HIV-1. For both groups, informed consent was obtained prior to enrolment. Testing for HIV was done by enzyme-linked immunosorbent assay (ELISA) and confirmed by Western blot. In addition, age and antibodies against syphilis were determined as risk factors of HIV infection.

RESULTS

The seroprevalence of HIV-1 infection did not decrease significantly over this time period, dropping from 28.3 to 25.1% between 2001 and 2007, but the prevalence of syphilis antibodies decreased from 27.9 to 11.1%. The data of 2001 and 2007 were compared to a third cohort from 1993, in which 21.5% of pregnant women were HIV-1-positive and 31.1% were Treponema pallidum hemagglutination assay (TPHA)-positive.

CONCLUSION

The current prevalence of HIV-1 infection in Uganda is still high and there is a need for further promotion of HIV prevention and control services.

Fourteen years of surveillance of HIV-1 prevalence among pregnant women attending antenatal care clinics in western Uganda

This study monitored long-term temporal trends in HIV-1 prevalence in antenatal clinic attendees living in western Uganda. Semi-annual data collection was done from 1991 to 2004. For each woman the following data were recorded: HIV-1 status, age, educational status, marital status, occupation and parity. The results show that the overall HIV-1 prevalence was 15.3% during the entire time period (urban 21.3%, semi-urban 12.7% and rural 7.1%). Between 1991 and 2004, we observed a gradual decline in the HIV-1 prevalence. The decline was most pronounced in urban women aged 15-19 years old and least pronounced in rural women aged 20-24 years. Women above 25 years of age did not show any decline in HIV-1 prevalence over time. The declining HIV-1 prevalence in the younger age groups (15-24 years) likely represents a declining risk for acquiring HIV infection as we have previously shown in the urban sub-sample of this data set.

A study of health facilities: implications for reproductive health and HIV/AIDS programs in southern Sudan

In October 2001, a pilot project to design strategies to reduce HIV/AIDS transmission and improve related reproductive health practices was initiated in southern Sudan. A health facility assessment was conducted in order to determine the type and scope of care given to clients with sexually transmitted infections (STIs). It was found that many health care practitioners did not have basic training in STI diagnosis and management, and no practitioner had training in the syndromic approach. Standardized drug kits received by public facilities did not provide enough STI drugs to serve the population. Private drug stores were the only facilities where condoms were available, though condoms were not sold to women who came to purchase them without their husbands. An adequately functioning health system will be difficult to achieve without ongoing training and supervision, adequate supplies and equipment, and proper rebuilding of infrastructure and systems, such as roads, communication, and education.

Linking anthropological analysis and epidemiological evidence: formulating a narrative of HIV transmission in Acholiland of northern Uganda

For twenty years, a region of northern Uganda known as Acholiland has been heavily affected by war, leading to the formation of internally displaced people's camps, rape, transactional sex and child abductions. While it is clear that the war has had onerous consequences for the health of the Acholi people, the specific impact of the war on HIV transmission remains unclear, as the epidemiological evidence presents an ambiguous picture of HIV prevalence patterns. Other than a few non-governmental organization reports, very little qualitative data exists about the impact of HIV on the Acholi population. Attempting to formulate a clearer narrative of HIV transmission in Acholiland, this paper jointly analyses the historical and political context of the Acholi people and the war, the epidemiologic evidence of HIV prevalence patterns, and the ethnographic perspectives of Acholi healthcare workers and patients living with HIV/AIDS. Juxtaposing these sources of information allows for the emergence of a rich understanding of HIV in Acholiland. It is argued that three specific forms of violence--physical, symbolic and structural--create vulnerability to HIV infection in Acholiland, although to variable degrees dependent on location. The ethnographic evidence presented regarding HIV's impact on Acholiland suggests that an incorporation of historical, political, cultural and social factors must form the backbone of efforts both to understand HIV transmission and design strategies for curbing the epidemic in war settings.

High potential of escalating HIV transmission in a low prevalence setting in rural Tanzania

Background

Previous surveillance among antenatal clinic (ANC) attendees within the remote rural Manyara and Singida regions in Tanzania identified an imminent but still, relatively low HIV epidemic. We conducted a population-based HIV study to identify risk factors and validate the representativeness of ANC-based estimates.

Methods

Using a two-stage cluster sampling approach, we enrolled and then interviewed and collected saliva samples from 1,698 adults aged 15–49 years between December 2003 and May 2004. We anonymously tested saliva samples for IgG antibodies against HIV using Bionor HIV-1&2 assays ^®. Risk factors for HIV infection were analysed by multivariate logistic regression using the rural population of the two regions as a standard.

Results

The prevalence of HIV in the general population was 1.8% (95%CI: 1.1–2.4), closely matching the ANC-based estimate (2.0%, 95% CI: 1.3–3.0). The female to male prevalence ratio was 0.8 (95%CI 0.4–1.7). HIV was associated with being a resident in a fishing community, and having recently moved into the area. Multiple sexual partners increased likelihood of HIV infection by 4.2 times (95% CI; 1.2–15.4) for men. In women, use of contraceptives other than condoms was associated with HIV infection (OR 6.5, 95% CI; 1.7–25.5), while most of the population (78%) have never used condoms.

Conclusion

The HIV prevalence from the general population was comparable to that of pregnant women attending antenatal clinics. The revealed patterns of sexual risk behaviours, for example, close to 50% of men having multiple partners and 78% of the population have never used a condom; it is likely that HIV infection will rapidly escalate. Immediate and effective preventive efforts that consider the socio-cultural contexts are necessary to reduce the spread of the infection.

Evaluating two adjustment methods to extrapolate HIV prevalence from pregnant women to the general female population in sub-Saharan Africa

OBJECTIVE

To evaluate two methods for estimating HIV prevalence among the general female population of reproductive age by adjusting data observed among antenatal clinic (ANC) attendees.

METHODS

We adjusted the HIV prevalence among ANC attendees in Fort Portal (Uganda; 1994-1995), Mwanza municipality (Tanzania; 1990-1991), rural Mwanza (Tanzania; 1991-1993), Mposhi district (Zambia; 1994), Chelston (Lusaka, Zambia; 1994, 1996 and 1998) and Ndola (Zambia; 1998), using firstly a method that accounts for differences in age-specific fertility by HIV serostatus and secondly a method that accounts for differences in HIV prevalence by fertility risk category and parity.

RESULTS

The non-adjusted HIV prevalence among ANC attendees underestimates the prevalence among the general female population by 8.0% in Chelston in 1998 and by between 20.7% and 31.9% in all other cases. The adjusted prevalence obtained using the first method underestimates the prevalence among the general female population by about 0.5% in Fort Portal and Mposhi; it overestimates that observed in Chelston in 1994 and 1996 by about 3.5%, and that observed in Ndola, urban Mwanza and rural Mwanza, by 6.5%, 10.6% and 12.8%, respectively. The second method (applied for only four sites) provides an overestimate of 7.0% in Chelston in 1994 and an underestimate of 3.8% and 2.1% in Ndola and rural Mwanza, respectively. Both adjustment methods overestimate the 1998 prevalence in Chelston, producing less accurate estimates than the non-adjusted data.

CONCLUSIONS

The HIV prevalence among women in the general population could be estimated fairly accurately by these methods in settings with mature epidemics.

HIV type 1 strains from East and West Africa are intermixed in Sudan

The genetic subtypes of HIV-1 in the Sudan epidemic have not been characterized. Here we report the partial sequencing and analysis of 30 strains collected from HIV-1-positive patients and blood donors in Khartoum in 1998 and 1999. From analysis of partial pol and env sequences, it was determined that 50% were subtype D and 30% were subtype C. Of interest, some subtype D clustered with those from East Africa whereas others joined subtype D from West Africa. Subtype A, subtype B, and three unique recombinants were also found, some partially unclassifiable. One unclassified strain matched another reported previously from the Democratic Republic of Congo. Sudan borders nine other African countries, and has suffered more than 20 years of civil strife with large population displacements. The intermixing of HIV-1 subtypes previously separated in Africa may be occurring there, with the potential to generate novel new strains by recombination.