Determinants of late antenatal care attendance among high parity women in Uganda: analysis of the 2016 Uganda demographic and health survey.

BACKGROUND: Timely and adequate Antenatal Care (ANC) effectively prevents adverse pregnancy outcomes and is crucial for decreasing maternal and neonatal mortality. High-parity women (5 + children) are at higher risk of maternal mortality. Limited information on the late timing of ANC among this risky group continues to hamper Uganda's efforts to reduce maternal mortality ratios and improve infant and child survival. This study aimed to determine factors associated with attendance of the first ANC after 12 weeks of gestation among high-parity women in Uganda. METHODS: This study was based on nationally representative data from the 2016 Uganda Demographic and Health Survey. The study sample comprised 5,266 women (aged 15-49) with five or more children. A complementary log-log regression model was used to identify factors associated with late ANC attendance among high-parity women in Uganda. RESULTS: Our findings showed that 73% of high parity women delayed seeking their first ANC visit. Late ANC attendance among high-parity women was associated with distance to the health facility, living with a partner, partner's education, delivery in a health facility, and Desire for more children. Women who did not find the distance to the health facility when going for medical help to be a big problem had increased odds of attending ANC late compared to women who found distance a big problem (AOR = 1.113, CI: 1.004-1.234), women not living with partners (AOR = 1.196, 95% CI = 1.045-1.370) having had last delivery in a health facility (AOR = 0.812, 95% CI = 0.709-0.931), and women who desired to have another child (AOR = 0.887, 95% CI = 0.793-0.993) had increased odds compared to their counterparts. CONCLUSIONS: To increase mothers' timely attendance and improve maternal survival among high-parity women in Uganda, programs could promote and strengthen health facility delivery and integrate family planning with other services such as ANC and postnatal care education to enable women to seek antenatal care within the recommended first trimester. This study calls for increased support for programs for education, sensitization, and advocacy for health facility-based deliveries. This could be done through strengthened support for VHT and community engagement activities.

"If your mother does not teach you, the world will ": a qualitative study of parent-adolescent communication on sexual and reproductive health issues in Border districts of eastern Uganda.

BACKGROUND: Adolescents experience a host of sexual and reproductive health (SRH) challenges, with detrimental SRH and socio-economic consequences. These include early sexual debut, sexually transmitted infections including HIV/AIDS, teenage pregnancy, and early childbearing. Parent-adolescent communication about SRH has significant potential to reduce adolescents' risky sexual behaviors. However, communication between parents and adolescents is limited. This study explored the facilitators and barriers to parent-adolescent communication about sexual and reproductive health. METHODS: We conducted a qualitative study in the border districts of Busia and Tororo in Eastern Uganda. Data collection entailed 8 Focus Group Discussions comprising of parents, adolescents (10-17 years), and 25 key informants. Interviews were audio-recorded, transcribed, and translated into English. Thematic analysis was conducted with the aid of NVIVO 12 software. RESULTS: Participants acknowledged the key role parents play in communicating SRH matters; however, only a few parents engage in such discussions. Facilitators of parent-adolescent communication were: having a good parent-child relationship which makes parents approachable and motivates children to discuss issues openly, a closer bond between mothers and children which is partly attributed to gender roles and expectations eases communication, and having parents with high education making them more knowledgeable and confident when discussing SRH issues with children. However, the discussions are limited by cultural norms that treat parent-child conversations on SRH as a taboo, parents' lack of knowledge, and parents busy work schedules made them unavailable to address pertinent SRH issues. CONCLUSION: Parents' ability to communicate with their children is hindered by cultural barriers, busy work schedules, and a lack of knowledge. Engaging all stakeholders including parents to deconstruct sociocultural norms around adolescent SRH, developing the capacity of parents to confidently initiate and convey accurate SRH information, initiation of SRH discussions at early ages, and integrating parent-adolescent communication into parenting interventions, are potential strategies to improve SRH communication between parents and adolescents in high-risk settings such as borders.

Factors that influence the satisfaction of people living with HIV with differentiated antiretroviral therapy delivery models in east Central Uganda: a cross-sectional study.

BACKGROUND: The World Health Organization (WHO) and the Uganda Ministry of Health recommend differentiated service delivery models (DSDMs) as patient-centered antiretroviral therapy (ART) mechanisms for people living with HIV/AIDS (PLHIV) with undetectable viral loads. We studied patient satisfaction with ART services, and its associated factors amongst PLHIV enrolled in DSDMs in Uganda. METHODS: This cross-sectional study involved a random sample of PLHIV accessing DSDM-related ART at nine facilities in East Central Uganda. Eligible patients were adult PLHIV (≥18 years), on ART, and enrolled for at least 12 months in one of three DSDMs: Community Client-Led ART Delivery (CCLAD), Community Drug Distribution Points (CDDP), or Fast-Track Drug Refill (FTDR). We collected data from June to July 2019. A validated tool measured satisfaction. General Estimating Equations with modified Poisson regression and exchangeable correlation structures accounted for clustering at health facilities and identified DSDM-related satisfaction factors. RESULTS: Of 842 participants enrolled, 530 (63.5%) accessed HIV care through CDDP, 166 (20.1%) through CCLAD, and 146 (16.3%) through FTDR; 541 (64.2%) were satisfied with DSDM services: 78.7% in CDDP, 42.8% in CCLAD, and 36.3% in FTDR. The delivery and treatment factors positively associated with satisfaction included: being enrolled on CDDP [adjusted prevalence ratio (aPR) = 1.51, 95% CI:1.47-1.56] or FTDR [aPR = 1.47, 95% CI:1.26-1.71] relative to CCLAD and being enrolled in a DSDM for more than 3 years [aPR = 1.28, 95% CI:1.11-1.48]. Poor ART adherence [aPR = 0.33, 95% CI:0.19-0.56] and having a baseline WHO HIV stage of 3 or 4 [aPR = 0.36, 95% CI:0.20-0.64] relative to stages 1 and 2 were negatively associated. Among socioeconomic factors, having lower transport costs (< $1.35) per clinic visit [aPR = 1.34, 95% CI:1.17-1.53], being employed [aPR = 1.61, 95% CI:1.38-1.87], and being single [aPR = 1.10, 95% CI:1.08-1.13] were positively associated with satisfaction; drinking alcohol at least once a week [aPR = 0.77, 95% CI:0.63-0.93] was negatively associated with patient satisfaction. CONCLUSIONS: Results showed that 64.2% of patients were satisfied with DSDM services. HIV service delivery and treatment factors (DSDM type, time in DSDM, WHO stage, ART adherence), plus social factors (employment and marital status, transport costs, alcohol consumption), were associated with patient satisfaction. DSDM implementers should tailor services to address these factors to improve patient satisfaction.

The meaning of fatherhood to men in relationships with female sex workers in Kampala, Uganda: The struggle to model the traditional parameters of fatherhood and masculinity.

Many women who engage in sex work in sub-Saharan Africa become pregnant, often unintentionally. There is limited attention paid to the experiences of fathers of children born to women engaged in sex work. We examine the meaning of fatherhood to these men, the significance of children, and how they navigate the economic and cultural challenges of fatherhood in this context. Analysis is based on ethnographic data from 13 men who identified as intimate long-term partners of female sex workers (FSW) in Kampala City, Uganda. Our findings illustrate how men who have children with FSW struggled to model the traditional parameters of fatherhood and masculinity. We found that men who had children with FSW faced hurdles fitting within the social construction of ideal fatherhood. Accepting fatherhood often started with doubts over the pregnancy because of the multiple partnerships of women. Men who only saw themselves as clients struggled to adjust to being fathers because of their perceptions of the social implications of fathering a child with a FSW. Integration of mothers who were also sex workers into the man's extended family was a challenge because of the fear of negative reactions from family members. However, when men accepted their roles as fathers, they started seeing value in their children. Due to poverty, most of the men fell short of the societal measures of masculinity, but children transformed their social status before their society and family. The provider role often used to define good fathering was a challenge for men. However, the financial support from FSW partners softened the burden and facilitated the creation of a family environment constructed to the perceived standards of the broader society. Our findings provide insights into the state of parenting among FSW and their partners which can guide interventions that are tailored to their unique circumstances.

Illicit Drug Use among Commercial 'Boda Boda' Motorcyclists in Uganda.

Background: Illicit drug use is a global public health problem with grave health and socio-economic consequences. Related intoxication has been associated with accidental injuries and fatalities. In Uganda, 67% of road traffic accidents are attributed to motorcyclists. Methods: This study assessed the prevalence and determinants of illicit drug use among commercial motorcyclists in Uganda, using a cross-sectional survey research design. We interviewed 785 commercial motorcyclists in the divisions of Nakawa, Rubaga, Makindye, and Kawempe of Kampala district. We used an on-spot saliva drug test kit to screen and detect the presence of illicit drugs. Data were analyzed using frequency distributions, cross tabulations and multi variable logistic regression. Results: Findings show that 11% of the cyclists used illicit drugs. The use of illicit drugs was associated with division of operation, religiosity, and whether a cyclist resided with a family. The odds of use of illicit drugs were higher among cyclists from Nakawa division compared to cyclists from Kawempe. Cyclists who went to places of worship on a weekly basis compared to those who were less frequent, and cyclists who lived with their families compared to those who did not, had reduced odds of use of illicit drugs. There are variations in the distribution of cyclists that use illicit drugs in Kampala. Religious commitment and residence with families had a mitigating influence on illicit drug use among commercial cyclists. Conclusion: Illicit drug use prevention, treatment, and harm reduction programs among cyclists should collaborate with faith-based organizations and other key stakeholders, and promote stable family relations.

Marginal men, respectable masculinity and access to HIV services through intimate relationships with female sex workers in Kampala, Uganda.

Masculinity influences men's sexual risk-taking behaviour and affects uptake of HIV services. We draw on data from a year-long (2019) ethnographic study focusing on men in relationships with female sex workers (FSW) in Kampala, Uganda to examine how and why two marginalised groups of people may interact to produce positive health behaviours. Data from in-depth interviews, focus group discussions and participant observation were collected and analysed. We discuss three main themes; the first of which focuses on marginalised masculinities and HIV risk. In this theme we show how accounts of men's life trajectories portrayed a remarkably similar pattern of early deprivation of opportunities and how this shaped construction of risky masculinities. The second theme describes men's relationships with FSW and how this facilitated access to HIV services. We discuss how very marginal women (FSWs) help very marginal men adopt more positive health behaviours. We show how threats to masculinities arising from sex work stigma, men's failure to have exclusive sexual rights over their FSW partner, and men's economic disadvantage are negotiated and dealt with to create an enabling environment for men's uptake of HIV services. The final theme focuses on the positive and negative practices of the men after engaging with HIV services. We conclude that the two marginalised groups can mobilise and combine new aspirations to produce positive health behaviours manifested through FSW assisting their male partners to access HIV services. We suggest that this perspective opens up new opportunities for engaging with marginalised groups and tackling the problem of high HIV infection among key populations.

Conflicted masculinities: understanding dilemmas and (re)configurations of masculinity among men in long-term relationships with female sex workers, in Kampala, Uganda.

This ethnographic study explores the experience of men in long-term relationships with sex workers and their construction of masculine identities in Kampala, Uganda. Data were collected in 2019 and comprise in-depth interviews with 13 male partners and two group discussions of women with long-term male partners. Thematic analysis used an intersectional lens to frame reconfigurations of gender and masculinity in the context of relationships with sex workers. All men had been clients of sex workers before progressing to become long-term partners. We discuss the complex ways in which men participated in value systems of respectability and reputation to (re)configure gender relations that made sense of their long-term relationships with sex workers. Men viewed their relationships with women through the normative lens of traditional masculine roles associated with monopoly over a partner's sexuality, provider and father. However, poverty, HIV, the failure to have exclusive sexual rights over a partner, and the shame associated with sex work intersected and disrupted masculinities. Despite this, men found meaning in these relationships through the woman's commitment to the relationship, her financial support, her help in accessing HIV services, and the children from the relationship, thereby attaining respectability and avoiding a crisis of masculinity.

Predictors of cervical cancer screening uptake in two districts of Central Uganda.

Uganda's cervical cancer age standardized incidence rate is four times the global estimate. Although Uganda's ministry of health recommends screening for women aged 25-49 years, the screening remains low even in the most developed region (Central Uganda) of the country. This study examined the demographic, social, and economic predictors of cervical cancer screening in Central Uganda with the aim of informing targeted interventions to improve screening. The cross-sectional survey was conducted in Wakiso and Nakasongola districts in Central Uganda. A total of 845 women age 25-49 years participated in the study. Data were analyzed at bivariate and multivariate levels to examine the predictors of CC (cervical cancer) screening. Only 1 in 5 women (20.6%) had ever screened for cervical cancer. Our multivariate logistic regression model indicated that wealth index, source of information, and knowledge about CC and CC screening were significantly associated with cervical cancer screening. The odds of cervical cancer screening were higher among rich women compared with poor women [AOR = 1.93 (95%CI: 1.06-3.42), p = 0.031)], receiving information from health providers compared with radios [AOR = 4.14 (95%CI: 2.65-6.48), p<0.001, and being more knowledgeable compared with being less knowledgeable about CC and CC screening [AOR = 2.46 (95%CI: 1.49-3.37), p<0.001)]. Overall cervical cancer screening uptake in central Uganda was found to be low. The findings of the study indicate that women from a wealthy background, who had been sensitized by health workers and with high knowledge about CC and CC screening had higher odds of having ever screened compared with their counterparts. Efforts to increase uptake of screening must address disparities in access to resources and knowledge.

Conducting in-depth interviews with and without voice recorders: a comparative analysis.

The use of audio recordings has become a taken-for-granted approach to generating transcripts of in-depth interviewing and group discussions. In this paper we begin by describing circumstances where the use of a recorder is not, or may not be, possible, before sharing our comparative analysis of audio-recorded transcriptions and interview scripts made from notes taken during the interview (by experienced, well-trained interviewers). Our comparison shows that the data quality between audio-recorded transcripts and interview scripts written directly after the interview were comparable in the detail captured. The structures of the transcript and script were usually different because in the interview scripts, topics and ideas were grouped, rather than being in the more scattered order of the conversation in the transcripts. We suggest that in some circumstances not recording is the best approach, not 'second best'.

Factors associated with HPV vaccination uptake in Uganda: a multi-level analysis.

BACKGROUND: The cervical cancer burden in Uganda is high amidst low uptake of HPV vaccination. Identification of individual and community factors associated with HPV vaccination are imperative for directed interventions. Conversely, in most Low and Middle Income Countries (LMICs) including Uganda this problem has not been sufficiently studied as the influence of individual and contextual determinants remains undetermined in spite of their substantial effect on HPV vaccine uptake. The aim of the study was to identify individual (school attendance status, age of girls, ethnicity, and amount of media exposure) and community (socioeconomic disadvantages) factors associated with HPV vaccination. METHODS: Based on a modified conceptual framework for health care utilization, hierarchical modelling was used to study 6093 girls, aged 10-14 years (level 1), nested within 686 communities (level 2) in Uganda by analyzing data from the 2016 Uganda Demographic and Health Survey. RESULTS: Majority (78%) of the girls had not been vaccinated. A number of both individual and community factors were significantly associated with HPV vaccination. The Odds of HPV vaccination were higher among girls age; 11, 13, and 14 compared to girls age 10 years, attending school compared to girls not attending school, who were; foreigners, Iteso, Karamajong, Banyoro, Basoga, and other tribe compared to Baganda, living in families with 1-8 members compared to those living in families with 9 or more members and middle social economic status compared to poor wealth quintile. CONCLUSIONS: Both individual and community factors show a noticeable effect on HPV vaccination. If higher vaccination rates are to be achieved in Uganda, these factors should be addressed. Strategies aimed at reaching younger girls, street children, out of school girls, and girls with lower SES should be embraced in order to achieve high vaccination uptake.

Synergistic Impact of Training Followed by On-Site Support on HIV Clinical Practice: A Mixed-Design Study in Uganda With Pre/Post and Cluster-Randomized Trial Components.

BACKGROUND: Task shifting can expand antiretroviral therapy access, but little is known about effective approaches to improve clinical practice among midlevel practitioners (MLPs) such as clinical officers, nurses, and midwives. The Integrated Infectious Diseases Capacity Building Evaluation compared training alone with training combined with on-site support (OSS). METHODS: Two MLPs each from 36 health facilities attended the 5-week Integrated Management of Infectious Disease training. After training, 18 facilities randomly assigned to arm A received OSS for 9 months, whereas 18 arm B facilities did not. Clinical faculty assessed MLP HIV clinical practice on 6 tasks: history taking, physical examination, laboratory investigations, diagnosis, treatment, and patient education. We analyzed the effect of training alone and training combined with OSS as the pre/post change within each arm. We analyzed the incremental effect of OSS with a difference-in-difference analysis that compared changes between arms. RESULTS: Training alone and training combined with OSS significantly improved clinical practice in patient history taking (13% and 24% increase, respectively), physical examination (54% and 71%), laboratory investigations (32% and 20%), and diagnosis (31% and 51%). Combined training and OSS also improved patient education significantly (72% increase). Effect sizes for training combined with OSS were larger than for training alone except for laboratory investigations, and the effects were robust in sensitivity analyses. The incremental effect of OSS on diagnosis was significant [adjusted relative risk = 1.23; 95% confidence interval = 1.00 to 1.50]. CONCLUSIONS: Combined training and OSS improved MLP HIV clinical practice over training alone and can contribute to continued expansion of access to antiretroviral therapy.

Reasons for participating in a randomised clinical trial: The volunteers' voices in the COSTOP trial in Uganda.

INTRODUCTION: The reasons why research participants join clinical trials remains an area of inquiry especially in low and middle income countries. METHODS: We conducted exit interviews with participants who took part in a trial which aimed to evaluate whether long term prophylaxis with cotrimoxazole can be safely discontinued among adults who have been stabilised on antiretroviral therapy (ART). Participants were all reported to be stable on ART and had been participating in the trial for between 12 and 36 months; at the end of the trial participants were interviewed using a semi-structured questionnaire. One of the objectives of the exit interview was to find out what motivated the participants to join the research. RESULTS: Participants gave personal reasons for joining the trial, frequently linked to their health and well-being as well as reduction of pill burden. CONCLUSION: We conclude that underlying reasons for joining clinical trials may extend beyond or can be different from the rationale given to the participants before enrolment by the research team. The reasons that motivate enrolment to clinical trials and research in general require further investigation in different settings. TRIAL REGISTRATION NUMBER: ISRCTN44723643.

Effect of On-Site Support on Laboratory Practice for Human Immunodeficiency Virus, Tuberculosis, and Malaria Testing.

OBJECTIVES: To evaluate the effect of on-site support in improving human immunodeficiency virus (HIV) rapid testing, tuberculosis (TB) sputum microscopy, and malaria microscopy among laboratory staff in a low-resource setting. METHODS: This cluster randomized trial was conducted at 36 health facilities in Uganda. From April to December 2010, laboratory staff at 18 facilities participated in monthly on-site visits, and 18 served as control facilities. After intervention, 128 laboratory staff were observed performing 587 laboratory tests across three diseases: HIV rapid testing, TB sputum microscopy, and malaria microscopy. Outcomes were the proportion of laboratory procedures correctly completed for the three laboratory tests. RESULTS: Laboratory staff in the intervention arm performed significantly better than the control arm in correctly completing laboratory procedures for all three laboratory tests, with an adjusted relative risk (95% confidence interval) of 1.18 (1.10-1.26) for HIV rapid testing, 1.29 (1.21-1.40) for TB sputum microscopy, and 1.19 (1.11-1.27) for malaria microscopy. CONCLUSIONS: On-site support significantly improved laboratory practices in conducting HIV rapid testing, TB sputum microscopy, and malaria microscopy. It could be an effective method for improving laboratory practice, without taking limited laboratory staff away from health facilities for training.

Effectiveness of educational outreach in infectious diseases management: a cluster randomized trial in Uganda.

BACKGROUND: Integrated Infectious Diseases Capacity Building Evaluation (IDCAP) teams designed and implemented two health worker in-service training approaches: 1) an off-site classroom-based integrated management of infectious diseases (IMID) course with distance learning aspects, and 2) on-site support (OSS), an educational outreach intervention. We tested the effects of OSS on workload and 12 facility performance indicators for emergency triage assessment and treatment, HIV testing, and malaria and pneumonia case management among outpatients by two subgroups: 1) mid-level practitioners (MLP) who attended IMID training (IMID-MLP) and 2) health workers who did not (No-IMID). METHODS: Thirty-six health facilities participated in the IDCAP trial, with 18 randomly assigned to Arm A and 18 to Arm B. Two MLP in both arms received IMID. All providers at Arm A facilities received nine monthly OSS visits from April to December 2010 while Arm B did not. From November 2009 to December 2010, 777,667 outpatient visits occurred. We analyzed 669,580 (86.1 %) outpatient visits, where provider cadre was reported. Treatment was provided by 64 IMID-MLP and 1,515 No-IMID providers. The effect of OSS was measured by the difference in pre/post changes across arms after controlling for covariates (adjusted ratio of relative risks = a RRR). RESULTS: The effect of OSS on patients-per-provider-per-day (workload) among IMID-MLP (aRRR = 1.21; p = 0.48) and No-IMID (aRRR = 0.90; p = 0.44) was not statistically significant. Among IMID-MLP, OSS was effective for three indicators: malaria cases receiving an appropriate antimalarial (aRRR = 1.26, 99 % CI = 1.02-1.56), patients with negative malaria test result prescribed an antimalarial (aRRR = 0.49, 99 % CI = 0.26-0.92), and patients with acid-fast bacilli smear negative result receiving empiric treatment for acute respiratory infection (aRRR = 2.04, 99 % CI = 1.06-3.94). Among No-IMID, OSS was effective for two indicators: emergency and priority patients admitted, detained or referred (aRRR = 2.12, 99 % CI = 1.05-4.28) and emergency patients receiving at least one appropriate treatment (aRRR = 1.98, 99 % CI = 1.21-3.24). CONCLUSION: Effects of OSS on workload were not statistically significant. Significant OSS effects on facility performance across subgroups were heterogeneous. OSS supported MLP who diagnosed and treated patients to apply IMID knowledge. For other providers, OSS supported team work to manage emergency patients. This evidence on OSS effectiveness could inform interventions to improve health workers' capacity to deliver better quality infectious diseases care.

Voluntary medical male circumcision for HIV prevention in fishing communities in Uganda: the influence of local beliefs and practice.

Local beliefs and practices about voluntary medical male circumcision (VMMC) may influence uptake and effectiveness. Data were gathered through interviews with 40 people from four ethnically mixed fishing communities in Uganda. Some men believed that wound healing could be promoted by contact with vaginal fluids while sex with non-regular partners could chase away spirits - practices which encouraged unsafe sexual practices. Information given by providers stressed that VMMC did not afford complete protection from sexually-transmitted infections, however, a number of male community members held the view that they were fully protected once circumcised. Both men and women said that VMMC was good not just for HIV prevention but also as a way of maintaining hygiene among the men. The implementation of VMMC in high-HIV prevalence settings needs to take account of local beliefs about circumcision, working with local religious/social group leaders, women and peers in the roll-out of the intervention.

Test and treat: the early experiences in a clinic serving women at high risk of HIV infection in Kampala.

At the end of 2013, the Government of Uganda issued guidance recommending provision of Anti-Retroviral Treatment (ART) to HIV-positive people in key populations, including female sex workers, regardless of CD4 cell count. We describe the implementation of this new guidance in a clinic serving women at high risk of HIV infection in Kampala. Between July and December 2015, we conducted repeat in-depth interviews with 15 women attending the clinic after the change in guidelines, to explore their perceptions regarding prompt ART initiation. The sample included some women who were HIV-negative and women who had both started and deferred ART. We conducted a data-led thematic analysis of the material from the interviews. A total of 257 of 445 eligible women had started ART; others were undecided or had not returned to the clinic after receiving the new information. Participants recounted varying experiences with the provision of prompt treatment. At an individual level, a history of treatment for opportunistic infections and other illnesses, coupled with relatively poor health, encouraged some to initiate ART promptly. However, knowledge of friends/relatives already on ART who had experienced side effects caused others to delay starting, fearing the same experience for themselves. A number of women questioned why they should start treatment when they were not sick. Situational factors such as work and residence (with many sharing single rooms) caused discomfort among newly diagnosed women who feared disclosure and stigma that would result from taking ART when they were not ill. Alcohol consumption and irregular working hours affected perceptions of future adherence, making prompt ART harder to embrace for some. Our findings show the challenges that influence the delay of treatment initiation, and/or the decision to defer receiving information on ART, with implications for the success of the test and treat programmes and guidelines.

Relationship dynamics and sexual risk behaviour of male partners of female sex workers in Kampala, Uganda.

Regular male partners of female sex workers (FSWs) represent an important population to reach with HIV-prevention interventions. This paper discusses the relationship dynamics and HIV/sexually transmitted infection risk behaviour of men involved with self-identified FSWs in Kampala. Between 2011 and 2014 we conducted repeat in-depth interviews with 42 male partners of FSWs attending a clinic for women at high risk of HIV-infection in Kampala. Men publicly struggled with the stigma of dating women who are considered to be engaged in a shamed profession, but privately saw meaning in these relationships. In coping with the stigma, some described the work of their partners in terms that distanced them from sex work, while others struggled to have the control that "being a man" demanded since they could not monitor all movements of their partners. Dealing with HIV disclosure was hard and seeking support was difficult for some of the men, leading to missed opportunities and guilt. Despite challenges, relationships with sex workers offered men some benefits such as access to much needed care and treatment. A few men also admitted to being motivated by material and financial benefits from sex workers who they perceived as being rich and this was one factor that helped them sustain the relationships. These findings offer insights into the complex relationship dynamics within high risk sexual partnerships. However, the findings suggest that effective interventions that are couple centred can be established to promote better health.

The social context of gender-based violence, alcohol use and HIV risk among women involved in high-risk sexual behaviour and their intimate partners in Kampala, Uganda.

This paper explores the interaction between gender-based violence and alcohol use and their links to vulnerability to HIV-infection in a population of women and their regular male partners in Kampala, Uganda. Data derive from 20 life history interviews (10 women and 10 men). Participants were drawn from a cohort of women at high risk of sexually transmitted infection (including HIV). Six of the women were current or former sex workers. Findings reveal that life histories are characterised by recurrent patterns of gender inequity related to violence, limited livelihood options and socioeconomic disadvantage. Overall, findings suggest women are able to negotiate safer sex and protect themselves better against abuse and violence from clients than from their intimate partners, although the status of men as 'client' or 'partner' is transitory and fluid. Among male respondents, alcohol led to intimate partner violence and high levels of sexual-risk taking, such as engagement with sex workers and reduced condom use. However, male partners are a heterogeneous group, with distinct and contrasting attitudes towards alcohol, condom use and violence. Actions to address gender-based violence need to be multi-pronged in order to respond to different needs and circumstances, of both women and men.

Effect of Educational Outreach Timing and Duration on Facility Performance for Infectious Disease Care in Uganda: A Trial with Pre-Post and Cluster Randomized Controlled Components.

BACKGROUND: Classroom-based learning is often insufficient to ensure high quality care and application of health care guidelines. Educational outreach is garnering attention as a supplemental method to enhance health care worker capacity, yet there is little information about the timing and duration required to improve facility performance. We sought to evaluate the effects of an infectious disease training program followed by either immediate or delayed on-site support (OSS), an educational outreach approach, on nine facility performance indicators for emergency triage, assessment, and treatment; malaria; and pneumonia. We also compared the effects of nine monthly OSS visits to extended OSS, with three additional visits over six months. METHODS: This study was conducted at 36 health facilities in Uganda, covering 1,275,960 outpatient visits over 23 months. From April 2010 to December 2010, 36 sites received infectious disease training; 18 randomly selected sites in arm A received nine monthly OSS visits (immediate OSS) and 18 sites in arm B did not. From March 2011 to September 2011, arm A sites received three additional visits every two months (extended OSS), while the arm B sites received eight monthly OSS visits (delayed OSS). We compared the combined effect of training and delayed OSS to training followed by immediate OSS to determine the effect of delaying OSS implementation by nine months. We also compared facility performance in arm A during the extended OSS to immediate OSS to examine the effect of additional, less frequent OSS. RESULTS: Delayed OSS, when combined with training, was associated with significant pre/post improvements in four indicators: outpatients triaged (44% vs. 87%, aRR = 1.54, 99% CI = 1.11, 2.15); emergency and priority patients admitted, detained, or referred (16% vs. 31%, aRR = 1.74, 99% CI = 1.10, 2.75); patients with a negative malaria test result prescribed an antimalarial (53% vs. 34%, aRR = 0.67, 99% CI = 0.55, 0.82); and pneumonia suspects assessed for pneumonia (6% vs. 27%, aRR = 2.97, 99% CI = 1.44, 6.17). Differences between the delayed OSS and immediate OSS arms were not statistically significant for any of the nine indicators (all adjusted relative RR (aRRR) between 0.76-1.44, all p>0.06). Extended OSS was associated with significant improvement in two indicators (outpatients triaged: aRR = 1.09, 99% CI = 1.01; emergency and priority patients admitted, detained, or referred: aRR = 1.22, 99% CI = 1.01, 1.38) and decline in one (pneumonia suspects assessed for pneumonia: aRR: 0.93; 99% CI = 0.88, 0.98). CONCLUSIONS: Educational outreach held up to nine months after training had similar effects on facility performance as educational outreach started within one month post-training. Six months of bi-monthly educational outreach maintained facility performance gains, but incremental improvements were heterogeneous.