Village-based AIDS prevention in a rural district in Uganda.

OBJECTIVE: To design, implement and evaluate a village-based AIDS prevention programme in a rural district in north-western Uganda. A baseline KAP survey of the general population was carried out to design a district-wide information campaign and condom promotion programme. Eighteen months later the impact achieved was measured through a second KAP survey, using the same methodology. METHODS: Anonymous structured interviews were conducted in March 1991 and October 1992 with 1486 and 1744 randomly selected individuals age 15-49, respectively. RESULTS: At 18 months, 60% of respondents had participated in an information session in the past year (47% women, 71% men) and 42% had received a pamphlet about AIDS (26% women, 58% men). Knowledge about AIDS, high initially (94%), reached 98%. More respondents knew that the incubation period is longer than one year (from 29% to 40%), and were willing to take care of a PWA (from 60% to 77%). Knowledge about condoms increased from 26 to 63% in women and 57 to 91% in men. Ever use of condoms among persons having engaged in casual sex in the past year increased from 6 to 33% in women, and 27 to 48% in men. Fifty per cent of condom users criticized lack of regular access to condoms. CONCLUSIONS: This is the first documented example of the impact a village-based AIDS prevention programme can achieve in a rural African community. Critical areas to be improved were identified, such as: women must be given better access to information, more attention must be paid to explain the asymptomatic state of HIV infection in appropriate terms, and condom social marketing must be developed.

PIP: A population-based knowledge, attitude and practice (KAP) survey was carried out as the first step in designing and implementing an AIDS prevention program. The design and implementation of an AIDS information campaign and condom promotion program following the results of the first KAP survey is described. Anonymous interviews on knowledge, attitudes, and practices related to AIDS were conducted in February-March 1991 on a representative sample of the adult population of the district. A 3-stage cluster sampling procedure (parish, village, household) was applied to 800 randomly selected households. In each household 1 man and 1 woman in the 15-49 age range were randomly selected and interviewed. A total of 1486 interviews (753 women, 733 men) were completed. More than 90% of respondents had heard of AIDS, and of these 90% knew that the disease is sexually transmitted and not curable. During September 1991-January 1992 of the information campaign, an estimated 50,000 people attended the village-based information sessions, and 45,000 pamphlets and 40,000 condoms were distributed. A second KAP survey was carried out during September-October 1992 to evaluate the impact of the AIDS prevention program. A total of 1744 questionnaires (874 women, 870 men) were completed and analyzed. Knowledge about the prevention of AIDS had improved substantially, from 40% to almost 70% of the respondents. Overall 39% of respondents knew that the time between infection and disease is more than one year, as compared to 26% at baseline. The proportion of respondents willing to take care of a family member suffering from AIDS had increased from 60% to 77% (p 0.001) between 1991 and 1992. In addition, the proportion of respondents who had ever used condoms increased from 23% to 46% among those who had engaged in casual sex in the past year. However, the overall proportion of respondents who had ever used a condom had remained at 3%. About half of the condom users complained about lack of access to condoms.

Country watch. Uganda.

PIP: In 1991, Medecins sans Frontieres initiated an HIV/AIDS prevention program in Moyo District, Uganda, with the goal of gradually transferring responsibility for it to local people through the training of AIDS control advisors (ACA). Informational pamphlets were developed along with an action plan for a village-based information campaign, followed by the insertion of 8 women and 22 men into a two-week training course in Moyo Town on prevention measures and communication. The ACAs were evaluated monthly both qualitatively and quantitatively with an overall evaluation conducted in January 1992. All villages had been visited several times in the first five months, with the ACAs meeting 50,000 people and distributing 45,000 pamphlets and 40,000 condoms. Community collaboration was excellent, although condoms were distributed to only adults and older teenagers in response to local cries that condom distribution encouraged immorality. Some language difficulties were also encountered. ACAs continued to distribute condoms upon request over the period February-August 1992, but concentrated upon drivers, beer brewers and their customers, traders, musicians, soldiers, barmaids, fishermen, teachers and school children, traditional healers and birth attendants, and religious leaders. Subsequent to this period, the advisors received a week of training on conducting KAP surveys. Refinements were made later in the program with the Ugandan assistant manager ultimately taking over field responsibility in May 1993. Although the ACA team was reduced from 30 to 10 people, it continues to work closely with all district authorities.^ieng

Sexual behaviors relevant to HIV transmission in a rural African population. How much can a KAP survey tell us?

KAP surveys have been proposed as a means to gather quantitative information on AIDS-related sexual behaviors, but the validity of survey results has not been tested. The validity of data gathered during a KAP survey in a rural district in Northern Uganda (N = 1486) was examined analyzing expected behavioral patterns, agreement of partner reports, and concordance of number of sexual contacts across gender. Patterns of sexual behavior and age trends are as expected. More men (50%) than women (18.5%) reported premarital sex. The likelihood of sexual intercourse before marriage increases with age at first marriage and with education. Women marry 5 years earlier than men, and the number of marriages increases with age. Peak incidence of casual sex occurs before age 25. The male/female ratio of casual sex is 4, as compared to about 3 in other African surveys. Single men are 2.5 times more likely to engage in casual sex than married males. Agreement of partner reports was examined for 392 couples selected by chance. 86% of the couples agreed on being polygamous or monogamous. On average men reported 1.3 (SD = 0.7) wives as compared to women reporting 1.5 (SD = 0.89) wives (P < 0.001). 16.8% of women declared more, and 2.8% less cowives than their husband (r = 0.65). Self-reports on frequency of sexual intercourse in the past month were examined for 256 monogamous couples. Mean frequencies differ (5.24 +/- 5.1 for men, 4.43 +/- 4.7 for women, P < 0.001). 42.8% of couples are in agreement within +/- 1 unit (r = 0.44). The total number of extra-marital and marital sex acts, as well as the total number of partners reported by each gender are similar. There is, however, a striking gender difference in reporting of casual partners in the past year. Data were found to be accurate at the aggregate level. However, accuracy of reporting at the individual level was found to be low. The gender difference in reporting of casual partners may be due to female underreporting, to not having captured prostitutes or to a different perception of the meaning of casual partnership. All KAP surveys should include a validity analysis, so as to provide a sense of the accuracy of the surveys and allow for comparison of the quality of different KAP surveys. There is an urgent need for a standardized approach to validating the findings from AIDS-related KAP surveys. Some of the indirect methods described here could be relevant for further use.

Mobilising Women for AIDS et STD Prevention in Moyo District; Northern Uganda

Objective:To identify appropriate strategies to raise HIV/AIDS awares and promote prevention amongst women in Moyo; a remote district of Nothern Uganda. Methods: For the last 21/22 years; an intensive mass information campain about HIVand AIDS transmision; prevention and control was carried out thtoughout the district; including condom distribution. A KAP survey (N