Rakai Community Research Articles

Prevalence and correlates of men's and women's alcohol use in agrarian, trading and fishing communities in Rakai, Uganda.

IntroductionUganda has one of the highest rates of alcohol use in sub-Saharan Africa but prevalence and correlates of drinking are undocumented in the Rakai region, one of the earliest epicenters of the HIV/AIDS epidemic in East Africa.MethodsWe analyzed cross-sectional data from 18,700 persons (8,690 men, 10,010 women) aged 15–49 years, living in agrarian, trading and fishing communities and participating in the Rakai Community Cohort Study (RCCS) between March 2015 and September 2016. Logistic regression models assessed associations between past year alcohol use and sociodemographic characteristics, other drug use and HIV status, controlling for age, religion, education, occupation, marital status, and household socioeconomic status.ResultsPast year alcohol prevalence was 45%. Odds of drinking were significantly higher in men (versus women) and fishing communities (versus agrarian areas). Odds of drinking increased with age, previous (versus current) marriage and past year drug use. By occupation, highest odds of drinking were among fishermen and (in women) bar/restaurant workers. Alcohol-related consequences were more commonly reported by male (vs. females) drinkers, among whom up to 35% reported alcohol dependence symptoms (e.g., unsteady gait). HIV status was strongly associated with alcohol use in unadjusted but not adjusted models.ConclusionsAlcohol use differed by gender, community type and occupation. Being male, living in a fishing community and working as a fisherman or restaurant/bar worker (among women) were associated with higher odds of drinking. Alcohol reduction programs should be implemented in Uganda’s fishing communities and among people working in high risk occupations (e.g., fishermen and restaurant/bar workers).

Migration, hotspots, and dispersal of HIV infection in Rakai, Uganda

HIV prevalence varies markedly throughout Africa, and it is often presumed areas of higher HIV prevalence (i.e., hotspots) serve as sources of infection to neighboring areas of lower prevalence. However, the small-scale geography of migration networks and movement of HIV-positive individuals between communities is poorly understood. Here, we use population-based data from ~22,000 persons of known HIV status to characterize migratory patterns and their relationship to HIV among 38 communities in Rakai, Uganda with HIV prevalence ranging from 9 to 43%. We find that migrants moving into hotspots had significantly higher HIV prevalence than migrants moving elsewhere, but out-migration from hotspots was geographically dispersed, contributing minimally to HIV burden in destination locations. Our results challenge the assumption that high prevalence hotspots are drivers of transmission in regional epidemics, instead suggesting that migrants with high HIV prevalence, particularly women, selectively migrate to these areas.

Intimate partner violence, HIV and sexually transmitted infections in fishing, trading and agrarian communities in Rakai, Uganda

BackgroundIntimate partner violence (IPV), HIV and sexually transmitted infections (STI) can contribute to disparities in population health, depending on the individual, social and environmental factors characterizing a setting. To better understand the place-based determinants and patterns of these key interrelated public health problems in Uganda, we compared risk factors for IPV, HIV and STI in fishing, trading and agrarian communities in Rakai, Uganda by gender.MethodThis study used cross-sectional data collected from 14,464 sexually active men (n = 6531) and women (n = 7933) as part of the Rakai Community Cohort Study, a population-based open cohort study of men and women aged 15–49 years. We used multilevel modified poisson regression models, which incorporated random intercepts for community and households. Factors associated with IPV, HIV and STI were assessed separately for men and women in fishing, trading and agrarian communities.ResultsA larger proportion of participants in the fishing communities than those in trading and agrarian communities were HIV positive, engaged in HIV risk behaviors, had STI symptoms and reported perpetration of or victimization by IPV. Female gender was a shared correlate of IPV, HIV and STI in the fishing communities. Engagement in multiple sexual relationships or partner’s engagement in multiple relationships were shared correlates of IPV, and HIV in agrarian communities and IPV and STI in trading communities.ConclusionPrograms should target factors at multiple levels to reduce risk for syndemic conditions of HIV, STI and IPV in Rakai, Uganda particularly among men and women in fishing communities.

HIV prevalence and uptake of HIV/AIDS services among youths (15\u201324 Years) in fishing and neighboring communities of Kasensero, Rakai District, South Western Uganda

BackgroundAlthough fishing communities have a significantly higher HIV prevalence than the general population, there is paucity of data on the burden of HIV and service utilization, particularly among the youth. We assessed the HIV prevalence and utilization of HIV prevention and treatment services among youth in Kasensero fishing community and the neighboring communities.MethodData were derived from the Rakai Community Cohort Study (RCCS) surveys conducted between 2013 and 2014. The RCCS is a population-based household survey that collects data annually from individuals aged 15–49 years, resident in 48 communities in Rakai and neighboring districts in Uganda. For this analysis, socio-demographic, behavioral and HIV-related data were obtained for 792 individuals aged 15–24 years. We used logistic regression to conduct bivariate and multivariable analysis to determine the factors that are independently associated with HIV-positive status and their corresponding 95% confidence intervals. Data were analyzed using STATA version 13.ResultsOverall HIV prevalence was 19.7% (n = 155); higher in Kasensero (n = 141; 25.1%) and Gwanda (n = 8; 11%) than in Kyebe (n = 6; 3.9%), p < 0.001 and among females (n = 112; 26.0%) than males (n = 43; 12.0%), p < 0.001. Uptake of HIV testing was high in both HIV-positive (n = 136; 89.5%) and HIV-negative youth (n = 435; 92%). Consistent condom use was virtually non-existent in HIV-positive youth (n = 1; 0.6%) compared to HIV-negative youth (n = 20; 4.2%). Only 22.4% (n = 34) of the HIV-positive youth were receiving antiretroviral therapy (ART) in 2013–2014; higher in the HIV-positive females (n = 31; 28.4%) than HIV-positive males (n = 03; 6.7%). Slightly more than half of males (n = 134; 53.8%) reported that they were circumcised; the proportion of circumcised youth was higher among HIV-negative males (n = 122; 58%) than HIV-positive males (n = 12; 27.9%). Factors significantly associated with HIV-positive status included living in Kasensero landing site (adjusted Odds Ratio [aOR] = 5.0; 95%CI: 2.22–13.01) and reporting one (aOR = 5.0; 95%CI: 1.33–15.80) or 2+ sexual partners in the past 12 months (aOR = 11.0; 95% CI; 3.04–36.72).ConclusionThe prevalence of HIV is high especially among young females and in landing site communities than in the peripheral communities. Uptake of HIV prevention and treatment services is very low. There is an urgent need for youth-friendly services in these communities.

Intimate partner violence as a predictor of marital disruption in rural Rakai, Uganda: a longitudinal study.

We assessed the association between intimate partner violence (IPV) and union disruption (divorce or separation) in the rural Ugandan setting of Rakai District. We analyzed longitudinal data collected from April 1999 to June 2006, from 6834 women (15-49years) living in 50 communities in Rakai. Participants were either officially married, traditionally married or in a consensual union during one or more surveys and completed at least one follow-up survey. The primary outcome was union disruption through divorce or separation from the primary sexual partner. Past year IPV ranged from 6.49% (severe physical abuse) to 31.99% (emotional abuse). Severe physical IPV was significantly associated with divorce/separation, after adjusting for other covariates (aOR=1.80, 95% CI 1.01-3.22). Another predictor of union disruption was a woman having two or more sexual partners in the past year (aOR=8.42, 95% CI 5.97-11.89). Factors protecting against divorce/separation included an increasing number of co-resident biological children and longer duration of union. IPV, particularly severe physical abuse, is an important risk factor for union disruption. Marital counseling, health education and interventions should address the role of IPV on the wellbeing of women and the stability of couples in Uganda.

Heterogeneity of the HIV epidemic in agrarian, trading, and fishing communities in Rakai, Uganda: an observational epidemiological study

SummaryBackgroundUnderstanding the extent to which HIV burden differs across communities and the drivers of local disparities is critical for an effective and targeted HIV response. We assessed community-level variations in HIV prevalence, risk factors, and treatment and prevention service uptake in Rakai, Uganda.MethodsThe Rakai Community Cohort Study (RCCS) is an open, population-based cohort surveying persons aged 15–49 in 40 communities. Participants are HIV tested and interviewed to obtain sociodemographic, behavioral, and health information. RCCS data from August 2011 to May 2013 were used to classify communities as agrarian (n=27), trading (n=9), or lakeside fishing sites (n=4). HIV prevalence was mapped using Bayesian methods, and variability across and within community classifications was characterized. Differences in HIV risk factors and uptake of antiretroviral therapy and male circumcision between community types were assessed.Findings17,119 individuals were included; 9215 (54%) were female. 9931 participants resided in agrarian, 3318 in trading, and 3870 in fishing communities. There was large variation in HIV prevalence, ranging from 9% to 43% across communities. Fishing communities had a higher median HIV prevalence (41%, range: 37–43%) compared to trading (17%, range: 11–22%) and agrarian communities (14%, range: 9–26%); ART and male circumcision coverage were significantly lower in fishing communities. Self-reported risk behaviors were significantly higher in men compared to women and in fishing communities compared to other community types.InterpretationThere is substantial heterogeneity in HIV prevalence, risk factors, and service uptake across communities within one region of Uganda. These findings underscore the need for local surveillance and have important implications for the design of targeted HIV responses. In particular, the extremely high HIV burden and risk behaviors, and low use of combination HIV prevention in fishing communities make these areas a priority for intervention.

Coerced sexual debut and lifetime abortion attempts among women in Rakai, Uganda

Objective To assess whether reported coercion at sexual debut is associated with a greater lifetime risk of attempting an abortion among women in Rakai, Uganda. Methods Analysis of data from sexually experienced, ever-pregnant women in a longitudinal, population-based, open cohort study in 56 rural communities in Rakai, Uganda (n = 4784). For univariate analysis, the t test was used for continuous variables and the Pearson χ 2 or Fisher exact tests for categorical variables. Multivariate logistic regression was used to control for potential confounding. Results Twenty percent of women reported coercion at sexual debut. Compared with women who reported consensual sexual debut, the adjusted odds ratio (OR) of subsequent abortion attempts among coerced women was 1.57 (95% CI, 1.11–2.20). Conclusion There is a need to protect women from sexual coercion, implement policies for prevention of violence, and provide comprehensive reproductive health care, including prevention of unwanted pregnancy and unsafe abortions.