NRU :: Browsing by Author "Ssekubugu, Robert"

Browsing by Author "Ssekubugu, Robert"

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Age-Disparate Relationships and HIV Prevalence among Never Married Women in Rakai, Uganda
(Journal of acquired immune deficiency syndromes, 2018) Mwinnyaa, George; Gray, Ronald H.; Grabowski, Mary K.; Ssekasanvu, Joseph; Ndyanabo, Anthony; Ssekubugu, Robert; Kagaayi, Joseph; Kigozi, Godfrey; Nakigozi, Gertrude; Serwadda, David M.; Laeyendecker, Oliver
Age-disparate relationships are associated with increased HIV prevalence. We determined whether the frequency of age-disparate relationships in never married women changed over time and whether they are associated with HIV prevalence in Rakai, Uganda. Methods: 10,061 never married women, aged 15–49 in the Rakai Community Cohort Study provided information on the age of their male sexual partners from 1997 to 2013. Logistic regression was used to assess trends in age-disparate relationships (≥5 years) between never married women and their male partners. Log-binomial regression was used to estimate adjusted prevalence ratios (adjPR) of HIV prevalence associated with age-disparate relationships. Results: 2,992 women (30%) had a male partner ≥5 years older which remained stable over time. The prevalence of HIV among women in age-disparate relationships was 14%, 10% for women in relationships with men 0–4 years older (adjPR 1.36, 95% CI 1.22, 1.53) not controlling women’s age, however after age adjustment the impact of age-disparate relationships on HIV prevalence was attenuated. Age-disparate relationships were associated with increased HIV prevalence among women aged 15–17 (adjPR 1.83, 95% CI 1.10, 3.19), but not in other age groups. Conclusions: The frequency of age-disparate relationships among never married women were unchanged over a 15-year period in Rakai, Uganda. Age-disparate relationships were associated with increased HIV prevalence among adolescents 15–17, but not older women.
Alcohol use and alcohol-related consequences are associated with not being virally suppressed among persons living with HIV in the Rakai region of Uganda
(Drug and Alcohol Dependence, 2021) Miller, Amanda P.; Pitpitan, Eileen V.; Kiene, Susan M.; Raj, Anita; Jain, Sonia; Luisa Zuniga, Marıa; Nabulaku, Dorean; Nalugoda, Fred; Ssekubugu, Robert; Nantume, Betty; Kigozi, Godfrey; Sewankambo, Nelson K.; Kagaayi, Joseph; Reynolds, Steven J.; Grabowski, Kate; Wawer, Maria; Wagman, Jennifer A.
Background: Alcohol use is common among persons living with HIV (PWH) in Uganda and associated with poor HIV care outcomes; findings regarding the relationship between alcohol use and viral suppression (VS) have been inconclusive. Methods: Data from two rounds (2017-2020) of the Rakai Community Cohort Study, an open population-based cohort study in the Rakai region, Uganda, were analyzed. Two alcohol exposures were explored: past year alcohol use and alcohol-related consequences. Multivariable models (GEE) were used to estimate associations between alcohol exposures and VS for the overall sample and stratified by sex, adjusting for repeated measurement. Causal mediation by ART use was explored. Results: Over half (55%) of participants (n=3,823 PWH) reported alcohol use at baseline; 37.8% of those reporting alcohol use reported alcohol-related consequences. ART use and VS at baseline significantly differed by alcohol use with person reporting alcohol use being less likely to be on ART or VS. Alcohol use was significantly associated with decreased odds of VS among women but not men (adj. OR 0.72 95% CI 0.58-0.89, p=0.0031). However, among males who use alcohol, experiencing alcohol-related consequences was significantly associated with decreased odds of VS (adj. OR 0.69 95% CI 0.54-0.88, p=0.0034). The relationships between both alcohol exposures and VS were not significant in models restricted to persons on ART. Conclusions: We provide sex-stratified estimates of associations between two alcohol measures and VS in the context of current HIV treatment guidelines. This study confirms that alcohol use is adversely associated with VS but ART use mediates this pathway, suggesting that initiation and retention on ART are critical steps to addressing alcohol-related disparities in VS.
Assessing the promotion of urine-diverting dry toilets through school-based demonstration facilities in Kalisizo, Uganda
(Journal of Water, Sanitation and Hygiene for Development, 2016) Trimmer, John T.; Nakyanjo, Neema; Ssekubugu, Robert; Sklar, Marc; Mihelcic, James R.; Ergas, Sarina J.
Urine-diverting dry toilets (UDDTs) are designed to recover nutrients and organic matter from human excreta for agricultural reuse. Their wider implementation could help address problems in areas where water scarcity limits coverage of sanitation systems and declining soil fertility jeopardizes nutritional security. Demonstration facilities can improve stakeholders’ views of UDDTs; however, it is uncertain whether these facilities should be located at households or institutions. Using a novel methodological approach that included qualitative data collection before and after introduction of demonstration UDDTs and quantitative monitoring of treatment conditions, this study evaluated changes in local attitudes and knowledge resulting from a UDDT promotion strategy at two primary schools in Uganda. Before introduction, students had little knowledge of UDDT facilities, while most attitude-related statements conveyed negative viewpoints and skepticism. After introduction and six months of operation, students exhibited increased knowledge, and 68% of attitude-related statements conveyed positive opinions that focused on the UDDTs’ long-term economic value and their role in creating a more hygienic school environment. These changes were seen in facility users and in other students at the schools who were non-users. In the future, with these improved perceptions, students could become compelling representatives for UDDTs within their communities, potentially increasing adoption.
Assessment of Changes in Risk Behaviors During 3 Years of Posttrial Follow-up of Male Circumcision Trial Participants Uncircumcised at Trial Closure in Rakai, Uganda
(American journal of epidemiology, 2012) Kong, Xiangrong; Kigozi, Godfrey; Nalugoda, Fred; Musoke, Richard; Kagaayi, Joseph; Latkin, Carl; Ssekubugu, Robert; Lutalo, Tom; Nantume, Betty; Iga, Boaz; Wawer, Maria; Serwadda, David; Gray, Ronald
Risk compensation associated with male circumcision has been a concern for male circumcision scale-up programs. Using posttrial data collected during 2007–2011 on 2,137 male circumcision trial participants who were uncircumcised at trial closure in Rakai, Uganda, the authors evaluated their sexual behavioral changes during approximately 3 years’ follow-up after trial closure. Eighty-one percent of the men self-selected for male circumcision during the period, and their sociodemographic and risk profiles were comparable to those of men remaining uncircumcised. Linear models for marginal probabilities of repeated outcomes estimate that 3.3% (P < 0.0001) of the male circumcision acceptors reduced their engagement in nonmarital relations, whereas there was no significant change among men remaining uncircumcised. Significant decreases in condom use occurred in both male circumcision acceptors (−9.2% with all partners and −7.0% with nonmarital partners) and nonacceptors (−12.4% and −13.5%, respectively), and these were predominantly among younger men. However, the magnitudes of decrease in condom use were not significantly different between the 2 groups. Additionally, significant decreases in sex-related alcohol consumption were observed in both groups (−7.8% in male circumcision acceptors and −6.1% in nonacceptors), mainly among older men. In summary, there was no evidence of risk compensation associated with male circumcision among this cohort of men during 3 years of posttrial follow-up.
Association of Medical Male Circumcision and Antiretroviral Therapy Scale-up With Community HIV Incidence in Rakai,Uganda
(American Medical Association, 2016) Kong, Xiangrong; Kigozi, Godfrey; Ssekasanvu, Joseph; Nalugoda, Fred; Nakigozi, Gertrude; Ndyanabo, Anthony; Lutalo, Tom; Reynolds, Steven J.; Ssekubugu, Robert; Kagaayi, Joseph; Bugos, Eva; Chang, Larry W.; Nanlesta, Pilgrim; Mary, Grabowski; Berman, Amanda; Quinn, Thomas C.; Serwadda, David; Wawer, Maria J.; Gray, Ronald H.
Randomized trials have shown that medical male circumcision( MMC)reduces maleHIVacquisition by50% to 60%,1-3 and that early initiation of antiretroviral therapy (ART) reduces HIV transmission by more than90%in HIV-discordant couples.4Mathematical modeling suggests that these interventions could mitigate the HIV epidemic in sub- Saharan Africa,5-7 but there is limited empirical evidence for the population-level effects of these interventions on HIV incidence in real-world programs. MMC provides direct protection against male HIV acquisition by removing the foreskin, which is rich in HIV target cells.8-10 The potential effect ofMMCon population-level HIV incidence depends on this biological effect, the level ofMMC coverage, risk profiles ofmenacceptingMMC,and whether behavioral disinhibition occurs following circumcision.
Cell Phones, Sexual Behaviors and HIV Prevalence in Rakai, Uganda: A Cross Sectional Analysis of Longitudinal Data
(AIDS and Behavior, 2020) Nalugoda, Fred; Kreniske, Philip; Hofer, Sarah; Zhong, Xiaobo; Wei, Ying; Grilo, Stephanie A.; Chen, Ivy; D. Kigozi, Ssebaggala; Kigozi, Godfrey; Lutalo, Tom; Ssekubugu, Robert; Nakawooya, Hadijja; Kagaayi, Joseph; Chang, Larry W.; Wawer, Maria J.; Gray, Ronald H.; Wang, Qianshu; Santelli, John S.
Cell phones have increased communication and connection across the globe and particularly in sub-Saharan Africa—with potential consequences for the HIV epidemic. We examined the association among ownership of cell phones, sexual behaviors (number of sexual partners, alcohol use before sex, inconsistent condom use), and HIV prevalence. Data were from four rounds (2010–2016) of the Rakai Community Cohort Study (N = 58,275). Sexual behaviors and HIV prevalence were compared between people who owned a cell phone to people who did not own a cell phone. We stratified analysis by younger (15–24 years) and older (25+ years) age groups and by gender. Using logistic regression and after adjusting for sociodemographic characteristics, we found cell phone ownership was independently associated with increased odds of having two or more sexual partners in the past 12 months across age and gender groups (young men AOR 1.67, 95% CI 1.47–1.90; young women AOR 1.28 95% CI 1.08–1.53; older men AOR 1.54 95% CI 1.41–1.69; older women AOR 1.44 95% CI 1.26–1.65). Interestingly, young men who owned cell phones had decreased odds of using condoms inconsistently (AOR 0.66, 95% CI 0.57–0.75). For young women, cell phone ownership was associated with increased odds of using alcohol before sex (AOR 1.38 95% CI 1.17–1.63) and increased odds of inconsistent condom use (AOR 1.40, 95% 1.17–1.67). After adjusting for sociodemographic characteristics, only young women who owned cell phones had increased odds of being HIV positive (AOR 1.27 95% CI 1.07–1.50). This association was not mediated by sexual behaviors (Adjusted for sociodemographic characteristics and sexual behaviors AOR 1.24, 95% CI 1.05–1.46). While cell phone ownership appears to be associated with increased HIV risk for young women, we also see a potential opportunity for future cell phone-based health interventions.
Contextual Barriers and Motivators to Adult Male Medical Circumcision in Rakai, Uganda
(Qualitative health research, 2013) Ssekubugu, Robert; Leontsini, Elli; Wawer, Maria J.; Serwadda, David; Kigozi, Godfrey; Kennedy, Caitlin E.; Nalugoda, Fred; Sekamwa, Richard; Wagman, Jennifer; Gray, Ronald H.
Medical male circumcision (MMC) is a central component of HIV prevention. In this study we examined barriers to and facilitators of MMC in Rakai, Uganda. Interviews and focus groups with MMC acceptors, decliners, and community members were collected and analyzed iteratively. Themes were developed based on immersion, repeated reading, sorting, and coding of data using grounded theory. Pain, medical complications, infertility, lack of empirical efficacy, waiting time before resumption of sex, and religion were identified as obstacles to MMC acceptance. Prevention and healing of sexually transmitted infections (STIs), access to HIV and other ancillary care, penile hygiene, and peer influence were key motivators. Voluntary counseling and testing for HIV, partner influence, and sexual potency were both barriers and motivators. Individual and societal factors, such as pain and religion, might slow MMC scale up. Health benefits, such as HIV/STI prevention and penile hygiene, are essential in motivating men to accept MMC.
Differential Impacts of HIV status on shortterm fertility desires among couples in Rakai, Uganda
(PLoS ONE, 2019) Song, Xiaoyu; Grilo, Stephanie A.; Mathur, Sanyukta; Lutalo, Tom; Ssekubugu, Robert; Nalugoda, Fred; Santelli, John S.
Fertility desires of female and male partners in current relationships are often correlated. We examined the influence of HIV seropositive status of female and male partners on shortterm fertility desires in Rakai, Uganda, a setting with high fertility and HIV infection rates. Methods Participants were couples (15–49 years old) enrolled in the Rakai Community Cohort Study, from 2011 to 2013 (n = 2,291). Cohen’s kappa coefficient was used to measure the correlation of female and male partners’ short-term fertility desires (measured as ‘wanting a child in the next 12 months’), in both total sample and stratified serostatus groups. HIV serostatus and additional characteristics of female and male partners were included in Poisson regression models to estimate the rate ratios (RR) for each partner’s short-term fertility desires. Individual and partner characteristics included HIV status, partner HIV status, age in years, partner age in years, educational attainment, number of living children, community of residence, and socioeconomic status (SES). Results Short-term fertility desires among female and male partners were moderately associated (Kappa = 0.37, p-value<0.001). The association was weakest among female sero-positive and male sero-negative couples (Kappa = 0.29, p-value<0.001). When adjusting for parity and other covariates in the model, women’s short-term fertility desires were significantly associated with their positive sero-status regardless of male partners’ sero-status (adjRR = 1.58, p<0.001 for F+M-; adjRR = 1.33, p = 0.001 for F+M+; in comparison with F-M-). Men’s short-term fertility desires were significantly associated with their positive sero-status, in addition to their female partners’ positive sero-status (adjRR = 1.23 with p-value = 0.022 for F-M+; adjRR = 1.42 with p-value<0.001 for F+M-; adjRR = 1.26 with p-value<0.001 for F+M +; in comparison with F-M-). When the differential effect of parity was included in the model, similar associations remained for both female and male partners when the number of living children was small, but largely reduced when the number of living children was large (3 or more). Conclusion Female and male partners in couple dyads demonstrated moderate agreements about short-term fertility desires. The HIV seropositive status of female partners was most strongly associated with short-term fertility desires of both genders, and this association was even stronger for women who had few or no living children.
Dynamics Of Pre-Exposure (PrEP) Eligibility due to Waxing and Waning of HIV Risk in Rakai, Uganda
(JAIDS Journal of Acquired Immune Deficiency Syndromes, 2022) Ssempijja, Victor; Ssekubugu, Robert; Kigozi, Godfrey; Nakigozi, Gertrude; Kagaayi, Joseph; Nalugoda, Fred; Nantume, Betty; Batte, James; Kigozi, Grace; Nakawooya, Hadijja; Serwadda, David; Reynolds, Steven J.
We conducted a retrospective population-based study to describe longitudinal patterns of prevalence, incidence, discontinuation, resumption, and durability of substantial HIV risk behaviors (SHR) for PrEP eligibility.The study was conducted among HIV-negative study participants aged 15-49 years that participated in survey rounds of the Rakai Community Cohort Study between August 2011 and June 2018. SHR was defined based on the Uganda national PrEP eligibility as either reporting sexual intercourse with >1 partner of unknown HIV status, non-marital sex without a condom or having transactional sex. Resumption of SHR meant resuming of SHR after stopping SHR, while persistence of SHR meant SHR on >1 consecutive visit. We used generalized estimation equations (GEE) with log-binomial regression models and robust variance to estimate survey-specific prevalence ratios (PR); GEE with modified Poisson regression models and robust variance to estimate incidence ratios for incidence, discontinuation, and resumption of PrEP eligibility.PrEP use should be tailored to the dynamic nature of PrEP eligibility. Preventive-effective adherence should be adopted for assessment of attrition in PrEP programs.
Effectiveness of Voluntary Medical Male Circumcision for Human Immunodeficiency Virus Prevention in Rakai, Uganda
(Clinical Infectious Diseases, 2021) Loevinsohn, Gideon; Kigozi, Godfrey; Kagaayi, Joseph; Wawer, Maria J.; Nalugoda, Fred; Chang, Larry W.; Quinn, Thomas C.; Serwadda, David; Reynolds, Steven J.; Nelson, Lisa; Mills, Lisa; Alamo, Stella; Nakigozi, Gertrude; Kabuye, Geoffrey; Ssekubugu, Robert; Tobian, Aaron A. R.; Gray, Ronald H.; Grabowski, M. Kathryn
The efficacy of voluntary male medical circumcision (VMMC) for human immunodeficiency virus (HIV) prevention in men was demonstrated in 3 randomized trials. This led to the adoption of VMMC as an integral component of the United States President’s Emergency Plan for AIDS Relief (PEPFAR) combination HIV prevention program in sub-Saharan Africa. However, evidence on the individual-level effectiveness of VMMC programs in real-world, programmatic settings is limited. A cohort of initially uncircumcised, non-Muslim, HIV-uninfected men in the Rakai Community Cohort Study in Uganda was followed between 2009 and 2016 during VMMC scale-up. Self-reported VMMC status was collected and HIV tests performed at surveys conducted every 18 months. Multivariable Poisson regression was used to estimate the incidence rate ratio (IRR) of HIV acquisition in newly circumcised vs uncircumcised men.
Estimation of Ascaris lumbricoides egg inactivation by free ammonia treatment of ash-amended UDDT vault products using stored urine in Uganda
(Journal of Water, Sanitation and Hygiene for Development, 2016) Trimmer, John T.; Nakyanjo, Neema; Ssekubugu, Robert; Sklar, Marc; Mihelcic, James R.; Ergas, Sarina J.
Urine-diverting dry toilets (UDDTs) are designed to recover nutrients and organic matter from human excreta for use as agricultural amendments, and have been promoted in many developing countries, including Uganda. Wider UDDT implementation could help address problems in areas where water scarcity limits sanitation coverage and/or declining soil fertility jeopardizes growing populations’ nutritional security. However, concerns have been raised regarding the safety of recovered UDDT vault products, which may contain persistent pathogens such as Ascaris lumbricoides eggs. A. lumbricoides eggs can be inactivated through elevation of free ammonia levels. This study assessed the feasibility of a secondary ammonia treatment strategy for UDDT ash-amended vault products using urine. Treatment parameters were measured in mixtures of urine, ash-amended vault products, and wood ash, a model was developed to account for temperature fluctuations, and A. lumbricoides egg inactivation times were estimated using a previously published model. A mixture containing two parts urine and one part ash-amended vault products was estimated to provide 2-log10 inactivation after 3 months of indoor storage (daily mean temperatures: 22.8±0.3 WC) or 2 months of outdoor storage (25.9±1.3 WC). This strategy could improve the safety of recovered products for agricultural use to improve the nutritional security of vulnerable populations.
Evaluating institutional capacity for research ethics in Africa: a case study from Botswana
(BMC Medical Ethics, 2013) Hyder, Adnan A.; Zafar, Waleed; Ali, Joseph; Ssekubugu, Robert; Ndebele, Paul; Kass, Nancy
The increase in the volume of research conducted in Low and Middle Income Countries (LMIC), has brought a renewed international focus on processes for ethical conduct of research. Several programs have been initiated to strengthen the capacity for research ethics in LMIC. However, most such programs focus on individual training or development of ethics review committees. The objective of this paper is to present an approach to institutional capacity assessment in research ethics and application of this approach in the form of a case study from an institution in Africa. Methods: We adapted the Octagon model originally used by the Swedish International Development Cooperation Agency to assess an organization along eight domains in research ethics: basic values and identity; structure and organization; ability to carry out activities; relevance of activities to stated goals; capacity of staff and management; administrative, financing and accounting systems; its relations with target groups; and the national context. We used a mixed methods approach to collect empirical data at the University of Botswana from March to December 2010. Results: The overall shape of the external evaluation Octagon suggests that strengths of the University of Botswana are in the areas of structure, relevance, production and identity; while the university still needs more work in the areas of systems of finance, target groups, and environment. The Octagons also show the similarities and discrepancies between the 'external' and 'internal' evaluations and provide an opportunity for exploration of these different assessments. For example, the discrepant score for 'identity' between internal and external evaluations allows for an exploration of what constitutes a strong identity for research ethics at the University of Botswana and how it can be strengthened. Conclusions: There is a general lack of frameworks for evaluating research ethics capacity in LMICs. We presented an approach that stresses evaluation from both internal and external perspectives. This case study highlights the university's rapid progress in developing research ethics capacity and points to some notable areas for improvement. We believe that such an empirically-driven and participatory assessment allows a more holistic measurement and promotion of institutional capacity strengthening for research ethics in LMICs.
Evaluation of current rapid HIV test algorithms in Rakai, Uganda
(Journal of virological methods, 2013) Galiwango, Ronald M.; Musoke, Richard; Lubyayi, Lawrence; Ssekubugu, Robert; Kalibbala, Sarah; Ssekweyama, Viola; Mirembe, Viola; Nakigozi, Gertrude; Reynolds, Steven J.; Serwadda, David; Gray, Ronald H.; Kigozi, Godfrey
Rapid HIV tests are a crucial component of HIV diagnosis in resource limited settings. In Uganda, the Ministry of Health allows for both serial and parallel HIV rapid testing using Determine, Stat- Pak and Uni-Gold. In serial testing, a non-reactive result on Determine ends testing. The performance of serial and parallel algorithms with Determine and Stat-Pak test kits was assessed. A cross-sectional diagnostic test accuracy evaluation using three rapid HIV test kits as per the recommended parallel test algorithm was followed by EIA-WB testing with estimates of the performance of serial testing algorithm. In 2520 participants tested by parallel rapid algorithms, 0.6% had weakly reactive result. Parallel testing had 99.7% sensitivity and 99.8% specificity. If Stat-Pak was used as the first screening test for a serial algorithm, the sensitivity was 99.6% and specificity 99.7%. However, if Determine was used as the screening test, sensitivity was 97.3% and specificity 99.9%. Serial testing with Stat-Pak as the initial screening test performed as well as parallel testing, but Determine was a less sensitive screen. Serial testing could be cost saving.
“He was no longer listening to me”: A qualitative study in six Sub-Saharan African countries exploring next-of-kin perspectives on caring following the death of a relative from AIDS
(AIDS Care, 2019) Ssekubugu, Robert; Renju, Jenny; Zaba, Basia; Seeley, Janet; Bukenya, Dominic; Ddaaki, William; Moshabela, Mosa; Wamoyi, Joyce; McLean, Estelle; Ondenge, Kenneth; Skovdal, Morten; Wringe, Alison
In the era of widespread antiretroviral therapy, few studies have explored the perspectives of the relatives involved in caring for people living with HIV (PLHIV) during periods of ill-health leading up to their demise. In this analysis, we explore the process of care for PLHIV as their death approached, from their relatives’ perspective. We apply Tronto’s care ethics framework that distinguishes between care-receiving among PLHIV on the one hand, and caring about, caring for and care-giving by their relatives on the other. We draw on 44 in-depth interviews conducted with caregivers following the death of their relatives, in seven rural settings in Eastern and Southern Africa. Relatives suggested that prior to the onset of poor health, few of the deceased had disclosed their HIV status and fewer still were relying on anyone for help. This lack of disclosure meant that some caregivers spoke of enduring a long period of worry, and feelings of helplessness as they were unable to translate their concern and “caring about” into “caring for”. This transition often occurred when the deceased became in need of physical, emotional or financial care. The responsibility was often culturally prescribed, rarely questioned and usually fell to women. The move to “care-giving” was characterised by physical acts of providing care for their relative, which lasted until death. Tronto’s conceptualisation of caring relationships highlights how the burden of caring often intensifies as family members’ caring evolves from “caring about”, to “caring for”, and eventually to “giving care” to their relatives. This progression can lead to caregivers experiencing frustration, provoking tensions with their relatives and highlighting the need for interventions to support family members caring for PLHIV. Interventions should also encourage PLHIV to disclose their HIV status and seek early access to HIV care and treatment services.
Heterogeneity of the HIV epidemic in agrarian, trading, and fi shing communities in Rakai, Uganda: an observational epidemiological study
(The lancet HIV, 2016) Chang, Larry W.; Grabowsk, Mary K.; Ssekubugu, Robert; Nalugoda, Fred; Kigozi, Godfrey; Nantume, Betty; Lessler, Justin; Moore, Sean M.; Quinn, Thomas C.; Reynolds, Steven J.; Gray, Ronald H.; Serwadda, David; Wawer, Maria J.
Understanding the extent to which HIV burden diff ers across communities and the drivers of lo cal disparities is crucial for an eff ective and targeted HIV response. We assessed community-level variations in HIV prevalence, risk factors, and treatment and prevention service uptake in Rakai, Uganda. Methods The Rakai Community Cohort Study (RCCS) is an open, population-based cohort of people aged 15–49 years in 40 communities. Participants are HIV tested and interviewed to obtain sociodemographic, behavioural, and health information. RCCS data from Aug 10, 2011, to May 30, 2013, were used to classify communities as agrarian (n=27), trading (n=9), or lakeside fi shing sites (n=4). We mapped HIV prevalence with Bayesian methods, and characterised variability across and within community classifi cations. We also assessed diff erences in HIV risk factors and uptake of antiretroviral therapy and male circumcision between community types. Findings 17 119 individuals were included, 9215 (54%) of whom were female. 9931 participants resided in agrarian, 3318 in trading, and 3870 in fi shing communities. Median HIV prevalence was higher in fi shing communities (42%, range 38–43) than in trading (17%, 11–21) and agrarian communities (14%, 9–26). Antiretroviral therapy use was signifi cantly lower in both men and women in fi shing communities than in trading (age-adjusted prevalence risk ratio in men 0·64, 95% CI 0·44–0·97; women 0·53, 0·42–0·66) and agrarian communities (men 0·55, 0·42–0·72; women 0·65, 0·54–0·79), as was circumcision coverage among men (vs trading 0·48, 0·42–0·55; vs agrarian 0·64, 0·56–0·72). Self-reported risk behaviours were signifi cantly higher in men than in women and in fi shing communities than in other community types. Interpretation Substantial heterogeneity in HIV prevalence, risk factors, and service uptake in Rakai, Uganda, emphasises the need for local surveillance and the design of targeted HIV responses. High HIV burden, risk behaviours, and low use of combination HIV prevention in fi shing communities make these populations a priority for intervention. Funding National Institute of Mental Health, the National Institute of Allergy and Infectious Diseases, the National Institute of Child Health and Development, and the National Institute for Allergy and Infectious Diseases Division of Intramural Research, National Institutes of Health; the Bill & Melinda Gates Foundation; and the Johns Hopkins University Center for AIDS Research.
High Rates of Pre-exposure Prophylaxis Eligibility and Associated HIV Incidence in a Population With a Generalized HIV Epidemic in Rakai, Uganda
(Journal of Acquired Immune Deficiency Syndromes, 2022) Ssempijja, Victor; Nakigozi, Gertrude; Ssekubugu, Robert; Kagaayi, Joseph; Kigozi, Godfrey; Nalugoda, Fred; Nantume, Betty; Batte, James; Kigozi, Grace; Nakawooya, Hadijja; Serwadda, David; Cobelens, Frank; Reynolds, Steven J.
The utility of using pre-exposure prophylaxis (PrEP) eligibility assessments to identify eligibility in general populations has not been well studied in sub-Saharan Africa. We used the Rakai Community Cohort Study to conduct a cross-sectional analysis to estimate PrEP eligibility and a cohort analysis to estimate HIV incidence associated with PrEP eligibility. Based on Uganda's national PrEP eligibility tool, we defined eligibility as reporting at least one of the following HIV risks in the past 12 months: sexual intercourse with more than one partner of unknown HIV status; nonmarital sex act without a condom; sex engagement in exchange for money, goods, or services; or experiencing genital ulcers. We used log-binomial and modified Poisson models to estimate prevalence ratios for PrEP eligibility and HIV incidence, respectively.
The HIV and sexually transmitted infection syndemic following mass scale-up of combination HIV interventions in two communities in southern Uganda: a population-based cross-sectional study
(The Lancet Global Health, 2022) Grabowski, M. Kate; Mpagazi, Josephine; Kiboneka, Stephen; Ssekubugu, Robert; Kereba, John Baptiste; Nakayijja, Annet; Tukundane, Julius; Kigozi, Godfrey; Galiwango, Ronald M; Kalibala, Sarah
Combination HIV prevention and treatment interventions (CHIs) have led to substantial declines in HIV incidence in sub-Saharan Africa; however, population-level data on non-HIV sexually transmitted infections (STIs) in the context of CHIs are rare. We aimed to assess STI burden following scale-up of CHIs in Uganda. The Sexually Transmitted Infection Prevalence Study (STIPS) was a cross-sectional study nested within a population-based cohort among inland agrarian and Lake Victoria fishing populations in southern Uganda. STIPS enrolled consenting residents aged 18–49 years in two communities (one inland and one fishing) between May and October, 2019, and measured the prevalence of chlamydia, gonorrhoea, trichomonas, syphilis, and herpes simplex virus 2 (HSV-2). Between May 27, 2019 and Oct 25, 2019, STIPS enrolled 1825 participants. HIV prevalence was 14·0% among the inland population and 39·8% among the fishing population, with about 90% HIV viral load suppression in both communities. Among inland and fishing populations, chlamydia prevalence was 9·6% (95% CI 7·9–11·7) and 9·9% (8·1–12·0), gonorrhoea prevalence 5·0% (3·8–6·7) and 8·4% (6·8–10·5), trichomonas prevalence 9·4% (7·7–11·5) and 12·2% (10·2–14·5), and HSV-2 prevalence 43·0% (39·9–46·3) and 64·4% (61·3–67·6), respectively. In the fishing population, syphilis seropositivity was 24·2% (21·5–27·2) with 9·4% (7·7–11·5) having high-titre (rapid plasma reagin ≥1:8) infection, including 16·9% (11·9–24·0%) of men living with HIV. Prevalence of at least one curable STI (chlamydia, gonorrhoea, trichomonas, or high-titre syphilis) was 51% higher among people living with HIV (vs HIV negative; adjusted prevalence risk ratio [PRR] 1·51; 95% CI 1·27–1·78), including among pregnant women (adjusted PRR 1·87, 1·11–3·17), with no differences by HIV suppression status. Despite near universal HIV treatment, STI burden remains extremely high in southern Uganda, particularly among people living with HIV. There is an urgent need to integrate STI care with HIV services in African settings.
HIV epidemiologic trends among occupational groups in Rakai, Uganda: A population-based longitudinal study, 1999–2016
(Public Library of Science, 2024-02-20) Popoola, Victor O; Kagaayi, Joseph; Ssekasanvu, Joseph; Ssekubugu, Robert; Kigozi, Grace; Ndyanabo, Anthony; Nalugoda, Fred; Chang, Larry W; Lutalo, Tom; Tobian, Aaron A. R; Kabatesi, Donna; Alamo, Stella; Mills, Lisa A; Kigozi, Godfrey; Wawer, Maria J; Santelli, John; Gray, Ronald H; Reynolds, Steven J; Serwadda, David; Lessler, Justin; Grabowski, M. Kate
Certain occupations have been associated with heightened risk of HIV acquisition and spread in sub-Saharan Africa, including female bar and restaurant work and male transportation work. However, data on changes in population prevalence of HIV infection and HIV incidence within occupations following mass scale-up of African HIV treatment and prevention programs is very limited. We evaluated prospective data collected between 1999 and 2016 from the Rakai Community Cohort Study, a longitudinal population-based study of 15- to 49-year-old persons in Uganda. Adjusted prevalence risk ratios for overall, treated, and untreated, prevalent HIV infection, and incidence rate ratios for HIV incidence with 95% confidence intervals were estimated using Poisson regression to assess changes in HIV outcomes by occupation. Analyses were stratified by gender. There were 33,866 participants, including 19,113 (56%) women. Overall, HIV seroprevalence declined in most occupational subgroups among men, but increased or remained mostly stable among women. In contrast, prevalence of untreated HIV substantially declined between 1999 and 2016 in most occupations, irrespective of gender, including by 70% among men (12.3 to 4.2%; adjPRR = 0.30; 95%CI:0.23–0.41) and by 78% among women (14.7 to 4.0%; adjPRR = 0.22; 95%CI:0.18–0.27) working in agriculture, the most common self-reported primary occupation. Exceptions included men working in transportation. HIV incidence similarly declined in most occupations, but there were no reductions in incidence among female bar and restaurant workers, women working in local crafts, or men working in transportation. In summary, untreated HIV infection and HIV incidence have declined within most occupational groups in Uganda. However, women working in bars/restaurants and local crafts and men working in transportation continue to have a relatively high burden of untreated HIV and HIV incidence, and as such, should be considered priority populations for HIV programming.
HIV viral suppression and geospatial patterns of HIV antiretroviral therapy treatment facility use in Rakai, Uganda
(AIDS (London, England), 2018) Billioux, Veena G.; Grabowski, Mary K.; Ssekasanvu, Joseph; Reynolds, Steven J.; Berman, Amanda; Bazaale, Jeremiah; Patel, Eshan U.; Bugos, Eva; Ndyanabo, Anthony; Kisakye, Alice; Kagaayi, Joseph; Gray, Ronald H.; Nakigozi, Gertrude; Ssekubugu, Robert; Nalugoda, Fred; Serwadda, David; Wawer, Maria J.; Chang, Larry W.
To assess geospatial patterns of HIV antiretroviral therapy (ART) treatment facility use and whether they were impacted by viral load (VL) suppression. Methods—We extracted data on the location and type of care services utilized by HIV-positive persons accessing ART between February 2015 and September 2016 from the Rakai Community Cohort Study (RCCS) in Uganda. The distance from RCCS households to facilities offering ART was calculated using the open street map road network. Modified Poisson regression was used to identify predictors of distance traveled and, for those traveling beyond their nearest facility, the probability of accessing services from a tertiary care facility. Results—1554 HIV-positive participants were identified, of whom 68% had initiated ART. The median distance from households to the nearest ART facility was 3.10 km (Interquartile range, IQR, 1.65–5.05), but the median distance traveled was 5.26 km (IQR, 3.00–10.03, p<0.001) and 57% of individuals travelled further than their nearest facility for ART. Those with higher education and wealth were more likely to travel further. 93% of persons on ART were virally suppressed, and there was no difference in the distance traveled to an ART facility between those with suppressed and unsuppressed VLs (5.26 km vs. 5.27 km, p=0.650). Conclusions—Distance traveled to HIV clinics was increased with higher socioeconomic status, suggesting that wealthier individuals exercise greater choice. However, distance traveled did not vary by those who were or were not virally suppressed.
Human immunodeficiency virus care cascade among sub-populations in Rakai, Uganda: an observational study
(Journal of the International AIDS Society, 2017) Billioux, Veena G.; Chang, Larry W.; Reynolds, Steven J.; Nakigozi, Gertrude; Ssekasanvu, Joseph; Grabowski, Mary K.; Ssekubugu, Robert; Nalugoda, Fred; Kigozi, Godfrey; Kagaayi, Joseph; Serwadda, David; Gray, Ronald H.; Wawer, Maria J.
To assess progress towards the UNAIDS 90–90–90 initiative targets, we examined the HIV care cascade in the population-based Rakai Community Cohort Study (RCCS) in rural Uganda and examined differences between sub-groups. Methods: Self-reports and clinical records were used to assess the proportion achieving each stage in the cascade. Statistical inference based on a 2 test for categorical variables and modified Poisson regression were used to estimate prevalence risk ratios (PRRs) and 95% confidence intervals (CI) for enrolment into care and initiating antiretroviral therapy (ART). Results: From September 2013 through December 2015, 3,666 HIV-positive participants were identified in the RCCS. As of December 2015, 98% had received HIV Counseling and Testing (HCT), 74% were enrolled in HIV care, and 63% had initiated ART of whom 92% were virally suppressed after 12 months on ART. Engagement in care was lower among men than women (enrolment in care: adjPRR 0.84, 95% CI 0.77–0.91; ART initiation: adjPRR 0.75, 95% CI 0.69–0.82), persons aged 15–24 compared to those aged 30–39 (enrolment: adjPRR 0.72, 95% CI 0.63–0.82; ART: adjPRR 0.69, 95%CI 0.60–0.80), unmarried persons (enrolment: adjPRR 0.84, 95% CI 0.71–0.99; ART adjPRR 0.80, 95% CI 0.66–0.95), and new in-migrants (enrolment: adjPRR 0.75, 95% CI 0.67–0.83; ART: adjPRR 0.76, 95% CI 0.67–0.85). This cohort achieved 98–65–92 towards the UNAIDS “90–90–90” targets with an estimated 58% of the entire HIV-positive RCCS population virally suppressed. Conclusions: This cohort achieved over 90% in both HCT and viral suppression among ART users, but only 65% in initiating ART, likely due to both an ART eligibility criterion of <500 CD4 cells/mL and suboptimal entry into care among men, younger individuals, and in-migrants. Interventions are needed to promote enrolment in HIV care, particular for hard-to-reach subpopulations.

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