Understanding the barriers to clubfoot treatment adherence in Uganda: a rapid ethnographic study.

PURPOSE: The Ponseti method has been demonstrated to be an effective, low-technology method of correcting congenital clubfoot. The purpose of this paper is to identify barriers to adherence to the Ponseti method of clubfoot treatment in Uganda. Understanding of barriers underlies successful and culturally appropriate approaches to program implementation. METHOD: A qualitative study (rapid ethnographic study), using semi-structured interviews, focus groups and observation, was conducted. Interviews were conducted with parents of children with clubfoot (42), adults with clubfoot (2), community leaders (40), traditional healers (39) and practitioners treating clubfoot (38). Some 48 focus groups (24 male, 24 female) were conducted with general community members to ascertain their opinions on the potential barriers. The data was collected by a team of researchers in 8 districts of Uganda over the period of one month. It was then coded manually by the researchers and sorted into themes. RESULTS: The barriers to adherence were classified into 6 themes: (i) problems with programmatic resource availability and regional differences, (ii) distance to treatment site, (iii) poverty, (iv) lack of paternal support, (v) caregiver's other responsibilities, and (vi) challenges of the treatment process. A number of factors that were helpful for encouraging adherence were also identified: (i) outreach and follow-up services, (ii) counselling/caregiver-practitioner partnership, (iii) family harmony and solidarity, and (iv) receiving quality care. CONCLUSIONS: Our study highlights the barriers to adherence in the treatment of clubfoot, as well as factors that could be helpful for overcoming these barriers. This information provides health planners with knowledge to assist them in meeting the needs of the population and implementing effective and appropriate awareness and treatment programs for clubfoot in Uganda.

Early undergraduate research experience at Makerere University Faculty of Medicine: a tool for promoting medical research.

BACKGROUND: Research is one of the key distinguishing features of an academic institution. The way an institution grooms its future researchers determines its long term survival. The ability to do and communicate ones research findings is so important that it is now an internationally recognized minimum competency for graduate of any medical school. To remain relevant the Faculty of Medicine Makerere University needs to identify research enhancing opportunities like undergraduate research experiences. METHODS: This was a cross sectional study involving 424 graduate and undergraduate students of Makerere University Medical School on the traditional curriculum. A self administered questionnaire was used to capture reported details of individual research experiences. RESULTS: There were 424 student respondents, 88% of whom were undergraduates (372/424). About 41% (176/424) of these respondents reported having had a previous research experience. Among the postgraduates 74% (37/50) reported having had a previous research experience compared with 68% (139/342) of the undergraduates [OR=4.16, 2.07-8.57]. The sum of individual undergraduate experiences had the strongest positive correlation with the total number of studies done by an individual [R=0.801]. CONCLUSION: Early, guided undergraduate research experience can be used to promote research within the Faculty of Medicine Makerere University. Running Head: Research Undergraduates Makerere.

Nutritional status and food consumption patterns of young children living in Western Uganda.

OBJECTIVES: The aim of this pilot study was to compare the nutritional status and food consumption patterns of children under five years. DESIGN: Quantitative, exploratory, cross sectional study. SETTING: Kabarole district, western Uganda. Kabarole district is a rural district with subsistence farming as the main income. SUBJECTS: Two hundred and five children between 12 and 72 months of age living in AIDS affected homes versus children living in non-AIDS affected homes were examined. RESULTS: Fifty-five percent of all children were stunted and 20.5% were underweight. There was no difference in the prevalence of malnutrition between children living in AIDS affected homes versus non-AIDS affected homes. Only children between 12-35 months suffered from a daily deficit in caloric intake. The older children consumed the basic recommended daily intake (RDI) for protein, fat, iron and vitamin A. Due to frequent disease episodes and limitations in the estimations of individual total energy expenditure, the results are likely underestimations of the children's true nutritional requirements. The type of foods given to children in AIDS affected homes and controls were quite similar. CONCLUSION: Young children in Kabarole district suffer from severe chronic malnutrition rates, but rates and feeding patterns are not different in AIDS affected versus non AIDS affected homes.

Age, temperature, and parasitaemia predict chloroquine treatment failure and anaemia in children with uncomplicated Plasmodium falciparum malaria.

The prevalence of chloroquine-resistant Plasmodium falciparum malaria has been increasing in sub-Saharan Africa and parts of South America over the last 2 decades, and has been associated with increased anaemia-associated morbidity and higher mortality rates. Prospectively collected clinical and parasitological data from a multicentre study of 788 children aged 6-59 months with uncomplicated P. falciparum malaria were analysed in order to identify risk factors for chloroquine treatment failure and to assess its impact on anaemia after therapy. The proportion of chloroquine treatment failures (combined early and late treatment failures) was higher in the central-eastern African countries (Tanzania, 53%; Uganda, 80%; Zambia, 57%) and Ecuador (54%) than in Ghana (36%). Using logistic regression, predictors of early treatment failure included younger age, higher baseline temperature, and greater levels of parasitaemia. We conclude that younger age, higher initial temperature, and higher baseline parasitaemia predict early treatment failure and a higher probability of worsening anaemia between admission and days 7 or 14 post-treatment.

HIV counselling and testing in rural Uganda: communities' attitudes and perceptions towards an HIV counselling and testing programme.

Study results on the assessment of a community-wide HIV counselling and testing programme are presented. The aim of this qualitative study was to elucidate whether HIV counselling and testing (HIV CT) was acceptable to a rural community and whether they expressed a need for it. From a total of 2,267 persons of Kigoyera Parish, western Uganda, who were HIV tested and counselled, 171 persons participated in 17 focus group discussions. Most participants expressed a strong need for HIV counselling and testing services. The counsellors were seen as competent and confidential. Community health workers were favoured as the preferred provider of HIV CT services. However, participants stressed that they should not come from the same community. Most participants felt that a HIV CT programme available only once is not enough and did not induce a change in sexual behaviour, e.g. increased condom use. They requested counselling services that are continuously offered. The study results also showed that there is a demand for HIV counselling services without being HIV tested.

Low impact of a community-wide HIV testing and counseling program on sexual behavior in rural Uganda.

Study results on the assessment of a community-wide HIV counseling and testing program are presented. The aim of this study was to elucidate whether HIV counseling and testing was effective in reducing high risk sexual behavior of a rural population in Uganda. From a total of 2,267 persons of Kigoyera Parish, western Uganda, who were HIV tested and counseled, 495 persons were selected and interviewed about their sexual behavior. Persons who were HIV tested showed no difference in sexual behavior compared to those who were not tested (condom use 4.3% vs. 5.5%, mean number of sexual partner in the past three months 1.8 vs. 2.0). The conclusion is that only knowing the HIV serostatus is not enough to reduce high risk behavior. The study results also showed that there is a demand for HIV counseling services without being HIV tested.

Education attainment as a predictor of HIV risk in rural Uganda: results from a population-based study.

We examined the association between education and prevalent HIV-1 infection in the Rakai district, rural Uganda based on a cross-sectional analysis of a population-based cohort. In 1990, 1397 men and 1705 women aged 13 years and older, were enrolled in 31 randomly selected communities. Strata were comprised of main road trading centres, secondary road trading villages and rural villages. Sociodemographic and behavioural data were obtained by interview and serum for HIV serostatus were obtained in the home. The analysis examines the association between sex-specific prevalent HIV infection and educational attainment, categorized as secondary, primary or none. The odds ratios (ORs) and 95% confidence intervals (95% CIs) of HIV infection were estimated, using no education as the referent group. Higher levels of education were associated with a higher HIV seroprevalence in bivariate analyses (OR 2.7 for primary and 4.1 for secondary education, relative to no education). The strength of the association was diminished but remained statistically significant after multivariate adjustment for sociodemographic and behavioural variables (adjusted OR of HIV infection 1.6 (95% CI: 1.2-2.1)) for primary education and 1.5 (95% CI: 1.0-2.2) for secondary education. Stratified multivariate analyses by place of residence indicated that the association between education and HIV prevalence was statistically significant in the rural villages, but not in the main road trading centres and intermediate trading villages. Educational attainment is a significant predictor of HIV risk in rural Uganda, in part because of risk behaviours and other characteristics among better educated individuals. Preventive interventions need to focus on better educated adults and on school-aged populations.

PIP: This is a cross-sectional analysis of a population-based cohort study conducted to examine both the associations between educational attainment and HIV-1 serostatus as well as the relationship between education and other HIV risk factors in Rakai district, Uganda. A total of 3102 respondents (1397 men and 1705 women aged 13 years and older) completed a questionnaire and provided blood samples. The samples of community clusters was stratified into three strata: trading centers on main roads, intermediate trading villages on secondary roads, and rural agricultural villages with no roads or only minor road connection. Analysis has shown a consistent association between higher level of educational attainment and HIV-1 prevalence among the residents. The strength of the association was decreased but remained statistically relevant after multivariate adjustment for sociodemographic and behavioral variables [adjusted OR for HIV infection, 1.6 (95% CI, 1.2-2.1) for primary education and 1.5 (95% CI, 1.0-2.2) for secondary education]. Stratified multivariate analyses by place of residence showed that the relationship between education and HIV prevalence was markedly higher in the rural villages compared to the other two strata. Education provides greater economic resources, which facilitate behaviors that put individuals at greater risk. Analysis of findings suggests that HIV prevention strategies should focus on the more educated individuals, particularly in rural settings and among younger women.

Age of male circumcision and risk of prevalent HIV infection in rural Uganda.

OBJECTIVE: To assess whether circumcision performed on postpubertal men affords the same level of protection from HIV-1 acquisition as circumcisions earlier in childhood. DESIGN: Cross-sectional study of a population-based cohort. SETTING: Rakai district, rural Uganda. METHODS: A total of 6821 men aged 15-59 years were surveyed and venous blood samples were tested for HIV-1 and syphilis. Age at circumcision was dichotomized into men who were circumcised before or at age 12 years (prepubertal) and men circumcised after age 12 years (postpubertal). Postpubertal circumcised men were also subdivided into those reporting circumcision at ages 13-20 years and > or = 21 years. RESULTS: HIV-1 prevalence was 14.1% in uncircumcised men, compared with 16.2% for men circumcised at age > or = 21 years, 10.0% for men circumcised at age 13-20 years, and 6.9% in men circumcised at age < or = 12 years. On bivariate analysis, lower prevalence of HIV-1 associated with prepubertal circumcision was observed in all age, education, ethnic and religious groups. Multivariate adjusted odds ratio of prevalent HIV-1 infection associated with prepubertal circumcision was 0.39 [95% confidence interval (CI), 0.29-0.53]. In the postpubertal group, the adjusted odds ratio for men circumcised at ages 13-20 years was 0.46 (95% CI, 0.28-0.77), and 0.78 (95% CI, 0.43-1.43) for men circumcised after age 20 years. CONCLUSIONS: Prepubertal circumcision is associated with reduced HIV risk, whereas circumcision after age 20 years is not significantly protective against HIV-1 infection. Age at circumcision and reasons for circumcision need to be considered in future studies of circumcision and HIV risk.

Population-based study of fertility in women with HIV-1 infection in Uganda.

BACKGROUND: To assess the effects of HIV-1 and other sexually transmitted infections on pregnancy, we undertook cross-sectional and prospective studies of a rural population in Rakai district, Uganda. METHODS: 4813 sexually active women aged 15-49 years were surveyed to find out the prevalence of pregnancy by interview and selective urinary human chorionic gonadotropin tests. The incidence of recognised conception and frequency of pregnancy loss were assessed by follow-up. Samples were taken to test for HIV-1 infection, syphilis, and other sexually transmitted diseases. FINDINGS: At time of survey 757 (21.4%) of 3544 women without HIV-1 infection or syphilis were pregnant, compared with 46 (14.6%) of 316 HIV-1-negative women with active syphilis, 117 (14.2%) of 823 HIV-1-positive women with no concurrent syphilis, and 11 (8.5%) of 130 women with both syphilis and HIV-1 infection. The multivariate adjusted odds ratio of pregnancy in HIV-1-infected women was 0.45 (95% CI 0.35-0.57); the odds of pregnancy were low both in HIV-1-infected women without symptoms (0.49 [0.39-0.62]) and in women with symptoms of HIV-1-associated disease (0.23 [0.11-0.48]). In women with concurrent HIV-1 infection and syphilis the odds ratio was 0.28 (0.14-0.55). The incidence rate of recognised pregnancy during the prospective follow-up study was lower in HIV-1-positive than in HIV-1-negative women (23.5 vs 30.1 per 100 woman-years; adjusted risk ratio 0.73 [0.57-0.93]). Rates of pregnancy loss were higher among HIV-1-infected than uninfected women (18.5 vs 12.2%; odds ratio 1.50 [1.01-2.27]). The prevalence of HIV-1 infection was significantly lower in pregnant than in non-pregnant women (13.9 vs 21.3%). INTERPRETATION: Pregnancy prevalence is greatly reduced in HIV-1-infected women, owing to lower rates of conception and increased rates of pregnancy loss. HIV-1 surveillance confined to pregnant women underestimates the magnitude of the HIV-1 epidemic in the general population.

PIP: A cross-sectional, prospective study conducted in Uganda's rural Rakai District indicated pregnancy prevalence is substantially reduced in women infected with HIV. A total of 4813 women 15-49 years of age who had at least one sexual partner in the previous year and were unaware of their HIV status were enrolled. 953 women (19.8%) were HIV-positive and 446 (9.3%) were diagnosed with active syphilis. 931 women (19.3%) became pregnant during the study period (1989-92). The pregnancy rate was 21.4% among women with no serologic evidence of HIV or syphilis compared with 14.6% among HIV-negative women with active syphilis and 8.5% among women infected with both HIV and syphilis. The pregnancy rate also was significantly higher among the 833 asymptomatic HIV-infected women (14.3%) than the 120 with clinical symptoms (7.5%). Symptomatic HIV-1 infection in male partners did not account for the lower pregnancy rate in HIV-positive women. After controls for age, marital status, gravidity, contraceptive use, lactation, subfertility, and time since last intercourse, the adjusted odds ratio of pregnancy among all HIV-positive women compared to women without HIV or syphilis was 0.45 (95% confidence interval, 0.35-0.57). Among the 3340 women who were not pregnant at baseline and were locatable, the pregnancy rate during follow-up was 23.5 per 100 woman-years among HIV-positive women and 30.1 per 100 woman-years among those without HIV or syphilis. Rates of pregnancy loss were higher among HIV-infected women (18.5%) than HIV-negative women (12.2%). The prevalence of HIV-1 infection was significantly lower in pregnant than nonpregnant women (13.9% and 21.3%, respectively). These findings indicate that, if HIV surveillance is confined to pregnant women, the prevalence of HIV-1 among women of reproductive age will be seriously underestimated.

Legislatory framework for private medical practice in Uganda.

BACKGROUND: In Uganda the private health sector has expanded dramatically in recent years with a striking proliferation of facilities for private medical practice which is particularly evident in urban areas. OBJECTIVES: The general objective of this study was to analyse the laws and regulations governing the private health sector in order to determine how they affect the operations and development of private medical practice in Uganda. METHODS: Between December 1995 and December 1996, we identified and reviewed all the laws, which affect private medical practice in Uganda. We discussed the contents of the laws with Ministry of Health officials and with representatives of private practitioners. We also made visits to a sample of clinics, which we inspected to ascertain compliance with the laws, and held interviews with managers of the clinics to get their views about the laws. RESULTS: Two categories of laws were identified. The first category includes two laws adopted in 1993, whose purpose is to ensure the availability at all times of efficacious and cost effective drugs in the country. The second category includes three laws, all adopted in 1996, which spell out the licensing procedures, supervision, disciplining and general control of different categories of professionals. The list of health professions, which are permitted to practice privately, was revised to include new categories, which were previously not allowed. We identified what we considered to be barriers to private health sector development, loopholes in the laws and also assessed the enforcement of the laws. The legal barriers include restrictions of drug imports, the requirement for the professionals to renew their practising licenses and to register the premises annually at one central place in the country, long periods of time mandated for acquiring experience before one can be permitted to practice privately and the finding that there are some capable professions which are still not allowed to practice privately. CONCLUSION: We made recommendations to the Ministry of Health to address all these barriers. We also recommended to the Ministry that non-professionals who have the ability to set up clinics should be allowed to register them provided they can engage professionals to operate them.

HIV-1 infection associated with abnormal vaginal flora morphology and bacterial vaginosis.

BACKGROUND: In-vitro research has suggested that bacterial vaginosis may increase the survival of HIV-1 in the genital tract. Therefore, we investigated the association of HIV-1 infection with vaginal flora abnormalities, including bacterial vaginosis and depletion of lactobacilli, after adjustment for sexual activity and the presence of other sexually transmitted diseases (STDs). METHODS: During the initial survey round of our community-based trial of STD control for HIV-1 prevention in rural Rakai District, southwestern Uganda, we selected 4718 women aged 15-59 years. They provided interview information, blood for HIV-1 and syphilis serology, urine for detection of Chlamydia trachomatis and Neisseria gonorrhoeae, and two self-administered vaginal swabs for culture of Trichomonas vaginalis and gram-stain detection of vaginal flora, classified by standardised, quantitative, morphological scoring. Scores 0-3 were normal vaginal flora (predominant lactobacilli). Higher scores suggested replacement of lactobacilli by gram-negative, anaerobic microorganisms (4-6 intermediate; 7-8 and 9-10 moderate and severe bacterial vaginosis). FINDINGS: HIV-1 frequency was 14.2% among women with normal vaginal flora and 26.7% among those with severe bacterial vaginosis (p < 0.0001). We found an association between bacterial vaginosis and increased HIV-1 infection among younger women, but not among women older than 40 years; the association could not be explained by differences in sexual activity or concurrent infection with other STDs. The frequency of bacterial vaginosis was similar among HIV-1-infected women with symptoms (55.0%) and without symptoms (55.7%). The adjusted odds ratio of HIV-1 infection associated with any vaginal flora abnormality (scores 4-10) was 1.52 (95% CI 1.22-1.90), for moderate bacterial vaginosis (scores 7-8) it was 1.50 (1.18-1.89), and for severe bacterial vaginosis (scores 9-10) it was 2.08 (1.48-2.94). INTERPRETATION: This cross-sectional study cannot show whether disturbed vaginal flora increases susceptibility to HIV-1 infection. Nevertheless, the increased frequency of HIV-1 associated with abnormal flora among younger women, for whom HIV-1 acquisition is likely to be recent, but not among older women, in whom HIV-1 is likely to have been acquired earlier, suggests that loss of lactobacilli or presence of bacterial vaginosis may increase susceptibility to HIV-1 acquisition. If this inference is correct, control of bacterial vaginosis could reduce HIV-1 transmission.

PIP: A study of 4718 women 15-49 years old in southwestern Uganda's Rakai district suggests that the loss of lactobacilli and the presence of bacterial vaginosis may increase susceptibility to HIV-1. These women were part of an ongoing community-based trial of sexually transmitted disease (STD) control as a strategy for AIDS prevention. The rate of HIV-1 infection among these women was 19.5%. Moderate bacterial vaginosis was detected in 44.5% of women, while 6.4% had severe bacterial vaginosis. STD rates were 10.2% for active or recent syphilis, 22.4% for trichomonas, 2.4% for gonorrhea, and 3.6% for chlamydia. The HIV rate was lowest (14.2%) among women with normal bacterial flora and highest (26.7%) among those with severe bacterial vaginosis. The HIV-abnormal flora association was higher in younger women, for whom HIV acquisition is likely to be recent, than in older women. In multiple logistic regression analyses adjusted for age, number of sexual partners, trichomonas, and syphilis, the odds ratio (OR) for HIV-1 infection associated with any abnormal vaginal flora was 1.52 (95% confidence interval [CI], 1.22-1.90) and with all bacterial vaginosis was 1.56 (95% CI, 1.24-1.97). These adjusted ORs were 1.50 (95% CI, 1.18-1.89) for moderate and 2.08 (95% CI, 1.48-2.94) for severe bacterial vaginosis. A cross-sectional study cannot ascertain whether the abnormalities in vaginal flora occurred before or after HIV seroconversion. However, the significantly increased proportion of HIV-infected women with depleted or absent vaginal lactobacilli is consistent with in vitro studies showing that hydrogen peroxidase-producing lactobacilli in vaginal flora inhibit HIV-1 viral replication. If the ongoing prospective study suggests a causal association with HIV, treatment of abnormal flora or bacterial vaginosis with inexpensive, effective drugs such as metronidazole may be indicated.

Trends in HIV-1 prevalence may not reflect trends in incidence in mature epidemics: data from the Rakai population-based cohort, Uganda.

OBJECTIVES: To assess whether trends in serial HIV-1 prevalence reflect trend in HIV incidence, and to decompose the effects of HIV-1 incidence, mortality, mobility and compliance on HIV-1 prevalence in a population-based cohort. DESIGN: Two-year follow up (1990-1992) of an open cohort of all adults aged 15-59 years, resident in a sample of 31 representative community clusters in rural Rakai District, Uganda. METHODS: A detailed household enumeration was concluded at baseline and in each subsequent year. All household residents were listed, and all deaths and in- and out-migrations that occurred in the intersurvey year wee recorded. In each year, all consenting adults were interviewed and provided a serological sample; 2591 adults aged 15-59 years were enrolled at baseline. RESULTS: HIV prevalence among adults declined significantly 1990 and 1992 (23.4% at baseline, 21.8% in 1991, 20.9% in 1992; P < 0.05). Declining prevalence was also observed in subgroups, including young adults aged 15-24 years (from 20.6 to 16.2% over 3 years; P < 0.02), women of reproductive age (from 27.1 to 23.5%; P < 0.05), and pregnant women (from 25.4 to 20.0%; not significant), However, HIV incidence did not change significantly among all adults aged 15-59 years (2.1 +/- 0.4 per 100 person-years of observation (PYO) in 1990-1991 and 2.0 +/- 0.3 per 100 PYO in 1991-1992], nor in population subgroups. HIV-related mortality was high (13.5 per 100 PYO among the HIV-positive), removing more infected persons that were added by seroconversion. Net out-migration also removed substantial numbers of HIV-positive individuals. CONCLUSIONS: In this mature HIV epidemic, HIV prevalence declined in the presence of stable and incidence. HIV-related mortality contributed most to the prevalence decline. Prevalence was not an adequate surrogate measure of incidence, limiting the utility or serial prevalence measures in assessing the dynamics of the HIV epidemic and in evaluating the impact of current preventive strategies.

PIP: Findings are reported from a 2-year follow-up study of an open cohort of people aged 15-59 years living in a sample of 31 representative community clusters in rural Rakai district, Uganda, to measure whether trends in serial HIV-1 prevalence reflect trends in HIV incidence, and to gain insight into the effects of HIV-1 incidence, mortality, mobility, and compliance upon HIV-1 prevalence. In each year of study, all consenting adults provided a serological sample and were interviewed; 2591 adults were enrolled at baseline. HIV prevalence among adults declined significantly between 1990 and 1992; from 23.4% in 1990, to 21.8% in 1991, and 20.9% in 1992. Declining prevalence was also observed in subgroups, including young adults aged 15-24 years from 20.6% to 16.2%, reproductive-age women from 27.1% to 23.5%, and pregnant women from 25.4% to 20.0%. The decline in HIV prevalence among pregnant women, however, is not significant. HIV incidence did not change significantly among all adults aged 15-59 years, nor in population subgroups. HIV-related mortality was 13.5/person-year of observation among those who were HIV-positive. Substantial numbers of HIV-infected individuals were also loss to emigration.

Trends in attitudes and behaviour relevant to AIDS in Ugandan community.

Behaviour-related preventive measures are still the main weapon against the spread of AIDS. Intensive AIDS prevention and control activities conducted over the last ten years need to be evaluated on the basis of their impact on attitudes and behaviour relevant to AIDS. The main objective of this study was to document and evaluate trends in attitudes and behaviour relevant to AIDS in a Ugandan community over a seven year follow up period. The study was a longitudinal community-based closed cohort. Periodic surveys were conducted on the study group and data on condom use, attitudes about condoms, rates of sexual partner change and reported frequency of sexually transmitted diseases were collected in all surveys. Data reported are from surveys conducted during 1987, 1992 and 1994 in which similar questions were asked and emerging trends identified. Reported condom use ever, increased from 3.9% in 1987 to 10.1% in 1992 and to 27.2% in 1994. This is a 7.3 fold increase over seven years. In females, reported use of condoms increased from 1.2% in 1987 to 18.2% in 1994 while in males it increased from 6.9% to 35.3% over the same period. In this study group there are still more people opposed to the ongoing intensive condom campaign than there are those supporting it. The percentage supporting the campaign was 28% in 1987, 26% in 1992 and 40.8% in 1994. This is a rising trend. The rate of sexual partner change has declined. During the baseline survey, 26.5% of the respondents reported that they had intercourse with two or more sexual partners in the six months period before the interview. This proportion decreased to 6.8% in 1992 but then increased to 17.1% in 1994. During the baseline survey, 2.6% of the study group reported that they had sexual intercourse with six or more partners during the six months period before the interview but during the 1992 and 1994 surveys, no one reported sexual intercourse with more than five partners during a similar period. The reported frequency of sexually transmitted diseases during a twelve month recall period, reflecting STD incidence, decreased from 3.5% in 1992 to 1.9% in 1994. In conclusion during the seven year followup period of this community-based closed cohort, we have identified a sharp increase in condom use, a reduced rate of sexual partner change and a decline in the reported frequency of sexually transmitted disease. The percentage of people supporting the condom campaign is rising. These are some of the outstanding outcomes of the AIDS prevention activities conducted in the country over the last 10 years.

PIP: Over the past decade, the Government of Uganda has implemented health education campaigns aimed at preventing the further spread of HIV infection and AIDS. A 7-year (1987-94) longitudinal closed cohort study (n = 1990) conducted in Kasangati evaluated the impact of these campaigns on condom attitudes and use, rates of sexual partner change, and sexually transmitted disease (STD) incidence. Kasangati is a semirural subcounty north of Kampala. Most encouraging was a 7.3-fold increase in condom use over the 7-year study period. Ever use of condoms rose from 4% in 1987 (baseline) to 10% in 1992 and to 27% in 1994. Support for campaigns that urge condom use outside of regular relationships rose from 28% in 1987 to 26% in 1992 and to 40.8% in 1994. The proportion of respondents reporting 2 or more sexual partners in the previous 6 months fell from 26.5% in 1987 to 6.8% in 1992, then increased to 17.1% in 1994. It is unclear whether the higher rate of sexual partner change in 1994 than 1992 represents an underreporting in 1992 or is related to increased rates of condom use. In the 1987 survey, 20.2% of respondents reported an STD episode in the preceding 5 years. In 1992 and 1994, when the recall period was reduced to 12 months before the survey, these rates were 3.5% and 1.9%, respectively. The numerous AIDS prevention campaigns in Uganda, combined with easier access to condoms, appear to have had a significant impact on AIDS-related attitudes and behaviors in Uganda.

Adolescents, sexual behaviour and HIV-1 in rural Rakai district, Uganda.

OBJECTIVES: To describe the epidemiology of HIV-1 infection among adolescents aged 13-19 years, in rural Rakai district, Uganda. STUDY DESIGN: Baseline survey and 2-year follow-up (1990-1992) of adolescents in a population-based, open rural cohort. METHODS: Annual enumeration and behavioral/serological survey of all consenting adolescents aged 13-19 years at recruitment, residing in 31 randomly selected community clusters. RESULTS: At baseline, of 909 adolescents present in study clusters, 824 (90.6%) provided interview data and serological samples. No adolescents aged 13-14 years were HIV-infected. Among those aged 15-19 years, 1.8% of men and 19.0% of women were HIV-positive. Among young women aged 15-19 years in marital/consensual union, 21.3% were HIV-positive; this rate did not differ significantly from the 29.1% prevalence in those reporting non-permanent relationships; prevalence was significantly lower in women reporting no current relationship (4.3%). After multivariate adjustment, female sex, age 17-19 years, residence in trading centers/trading villages and a history of sexually transmitted disease symptoms remained significantly associated with HIV infection. Seventy-nine per cent of adolescents provided a follow-up serological sample. No young men aged 13-14 years seroconverted during the study; in young women aged 13-14 years, HIV seroincidence was 0.6 per 100 person-years (PY) of observation. Among young men aged 15-19 years, there were 1.1 +/- 0.6 seroconversions per 100 PY of observation prior to age 21 years; among women 15-19 years, the incidence rate was 3.9 +/- 1.0 per 100 PY of observation prior to age 21 years. The mortality rate among HIV-positive adolescents aged 15-19 years, at 3.9 per 100 PY of observation, was 13-fold higher than that among the HIV-uninfected. By 1992, knowledge of sexual transmission was almost universal, the proportions reporting multiple partners had decreased and condom use had increased over baseline. CONCLUSIONS: Adolescents, and young women in particular, are vulnerable to HIV infection. Despite reported behavioral changes, HIV incidence rates remain substantial, and there is a need for innovative HIV preventive measures.

Adolescent sexual networking and HIV transmission in rural Uganda.

Information on 861 adolescents shows that in 1991 36 per cent reported having been sexually active in the previous 12 months, but only 6.2 per cent had ever used a condom (11% males, 2.4% females). The HIV infection rate was 5.9 per cent overall, 0.8 per cent in males and 9.9 per cent in females. The proportion sexually active and the rate of HIV infection rise with age. The annual incidence of HIV infection was 2.0 per 100 person-years of follow-up among all adolescents, 0.8 in males and 3.0 in females. The annual mortality rate among HIV-negative adolescents was 0.37 per cent versus 3.92 per cent among the HIV-positive adolescents, a rate ratio of 10.6. Sexual network data were collected on 389 adolescents aged 15-19 years of whom 55 per cent were sexually active. The median age of first sexual intercourse was 15 years in either sex. The 214 adolescents reported 339 sexual relationships of which 38.5 per cent were with spouses, 36 per cent with boy or girl friends and 21 per cent with 'friends'. There were 52 concurrent sexual relationships reported by 35 adolescents. Males report higher rates of concurrent sexual relationships than females. The sexual partners of boys were mainly younger students and housemaids while the girls' partners were mainly older traders and salaried workers. Adolescents in this community report high rates of sexual activity and have complex sexual networks. They probably are important in the dynamics of HIV infection.

PIP: Interview and HIV serostatus data were obtained for 861 adolescents aged 13-19 years in 1991 living in Rakai district, Uganda. Although 36% reported having been sexually active during the previous 12 months, only 11% of males and 2.4% of females had ever used a condom. 0.8% of males and 9.9% of females were infected with HIV. The proportion of adolescents who are sexually active and the rate of HIV infection both increase with age. The annual incidence of HIV infection was 2.0 per 100 person-years of follow-up among all adolescents, 0.8 in males and 3.0 in females. The annual mortality rate among HIV-negative adolescents was 0.37% compared to 3.92% among the HIV-positive adolescents. Sexual networking data were collected from 389 adolescents aged 15-19 years of whom 55% were sexually active. The median age at first sexual intercourse was 15 years for both boys and girls. The 214 sexually active adolescents reported 339 sexual relationships of which 38.5% were with spouses, 36% with boyfriends or girlfriends, and 21% with friends. 52 concurrent sexual relationships were reported by 35 adolescents, with males reporting higher rates of concurrent sexual relationships than females. Boys' sex partners were mainly younger students and housemaids while the girls' partners were mainly older traders and salaried workers.

The social dynamics of HIV transmission as reflected through discordant couples in rural Uganda.

OBJECTIVE: To describe the role of men and women as sources of HIV transmission and to estimate HIV incidence among discordant couples resident in diverse rural communities in Uganda. SETTING: Rakai, a rural district in Uganda, East Africa. METHODS: A population-based cohort study, which has been conducted as annual serological and behavioral surveys since 1989. Community clusters were stratified into trading centers on main roads, intermediate trading villages on secondary roads and agricultural villages off roads. In the 1990 survey round, serological data were available for 79 discordant and 411 concordant HIV-negative couples aged 13-49 years. The present analysis examines sex-specific seropositivity associated with place of residence and the incidence of seroconversion among discordant couples between 1990 and 1991. RESULTS: Seventy-nine discordant couples were followed; the HIV-positive partner was male in 44 couples (57%) and female in 35 couples (43%). There was marked variation in the sex of the seropositive partner by place of residence: women were the HIV-positive partner in 57% of couples from trading centers, 52% from intermediate villages, and 20% from agricultural communities (P < 0.008). Condom use was higher in discordant couples in which the man was the uninfected partner (17.1%) rather than the woman (9.5%). HIV-positive women, but not HIV-positive men, reported significantly more sexual partners and more genital ulcers than seronegative individuals of the same sex. Seroincidence rates among men and women in discordant relationship were 8.7 and 9.2 per 100 person-years (PY), respectively, which was much higher than in concordant seronegative couples (men, 0.82; women, 0.87 per 100 PY). CONCLUSIONS: In this Ugandan population, men are the predominant source of new infections in rural villages. Risk factors and preventive behaviors vary with the sex of the infected partner, and seroconversion rates are similar in both sexes.

PIP: The analysis of marital relationships in rural Uganda in which one partner is infected with human immunodeficiency virus (HIV) revealed important information about the social dynamics of HIV transmission. As part of an ongoing cohort study of over 3000 adults in southwestern Uganda's Rakai district, data were collected on 79 discordant couples. The HIV-infected partner was male in 44 couples (57%) and female in 35 couples (43%). In the trading centers and intermediate trading villages, women were more likely to be the HIV-infected partner (57% and 52%, respectively); in rural areas, however, the male partner was the HIV carrier in 80% of discordant couples. 14.3% of women in female HIV-positive compared to only 2.1% of those in male HIV-positive discordant relationships reported two or more sexual partners in the year preceding the interview; there was no significant difference on this factor among HIV-positive and HIV-negative men (48.8% and 45,7%, respectively). 17.1% of seronegative men with HIV-infected wives compared to only 9.5% of seropositive men with seronegative wives used condoms with their partner. During the one-year study period, the rate of seroconversion was 8.7/100 years of observation for men and 9.2 for women. Extrapolation of the data from this study to the district as a whole suggests that 18.7% of couples have at least one HIV-infected member. Needed are campaigns to promote monogamy and condom use, particularly among men from rural areas who travel to high prevalence trading areas.

The declining HIV seroprevalence in Uganda: what evidence?

PIP: Papers presented at the Ninth International Conference on AIDS and STDs in Africa, held in Kampala in December 1995, indicate that HIV prevalence has been declining in several sectors of the population in Uganda over the past few years. This paper reviews the following relevant presentations: studies among pregnant women in Mulago hospital, Kampala; sentinel surveillance data; a community-based study of HIV in Masaka district; a community-based study in Rakai district; and persons attending voluntary HIV testing in towns in Uganda. Most of the data presented come from urban areas. Approximately 90% of the country's population, however, lives in rural areas. All of the studies document declining trends in HIV prevalence in the populations studied. The author considers whether these findings represent what is happening in the general population and what is behind this trend. On the basis of the presentations made during the conference, it seems that the main factors affecting current HIV seroprevalence trends in Uganda are HIV incidence, HIV-related mortality, and demographic changes. The role of each of these factors is discussed in light of the available evidence. More specifically, there appears to be a real decline in HIV seroprevalence in some population groups in Uganda. Very high HIV-related mortality, the movement of many young people into the adult demographic category while retaining their HIV-negative status, and probably a lower HIV incidence rate than that prevailing before 1990 are some of the explanations for the observed trend.^ieng

Demographic impact of HIV infection in rural Rakai district, Uganda: results of a population-based cohort study.

OBJECTIVES: To examine HIV-1-related mortality and demographic impact in a high HIV prevalence rural district of Uganda. DESIGN: One-year follow-up (1990-1991) in a population-based rural cohort. SETTING AND PARTICIPANTS: Annual enumeration of all consenting residents of 1945 households in 31 randomly selected community clusters in Rakai District. Subjects provided yearly HIV serological samples, behavioral and health information. MAIN OUTCOME MEASURE: Mortality in HIV-infected and uninfected persons. RESULTS: Mortality among HIV-seropositive adults aged > or = 15 years of 118.4 per 1000 person-years (PY) was substantially higher than in HIV-seronegative adults [12.4 per 1000 PY; relative risk (RR), 9.5; 95% confidence interval (CI), 6.0-14.9]. Infant mortality among offspring of HIV-infected mothers was almost double that for uninfected women (210 compared with 111 per 1000 live births; RR, 1.9; 95% CI, 1.0-3.5). Adult HIV-related mortality was associated with HIV prevalence and, in this cohort, with higher education, non-agricultural occupation and residence in roadside trading centers. We estimate that adult HIV prevalence in the district is 13% and adult HIV attributable mortality 52%. For all ages combined, district HIV attributable mortality is 28%. CONCLUSION: HIV is the leading cause of adult death in Rakai. Its effects on mortality are particularly marked in the most economically active sectors. However, the overall crude birth rate in the district (45.7 per 1000 population) remains higher than the crude death rate (28.1 per 1000 population), resulting in continued rapid population growth.

Incidence of HIV-1 infection in a rural region of Uganda.

OBJECTIVE: To determine the incidence of infection with HIV-1 and the risk factors associated with seroconversion in three geographical strata of a rural Ugandan district. DESIGN: Serological, sociodemographic, and behavioural surveys of everyone aged 13 or more in 21 randomly selected communities at baseline and one year later. SETTING: Rural population of Rakai district, southwestern Uganda, residing in main road trading centres, secondary trading villages, and agricultural villages. SUBJECTS: In 1989, 1292 adults provided a blood sample and interview data; one year later, 778 survivors (77%) who had been seronegative at baseline provided follow up data. MAIN OUTCOME MEASURES: Incidence of HIV infection in relation to individual characteristics and risk factors, including place of residence. RESULTS: Incidence of HIV infection in all adults was 2.1/100 person years of observation (SE 0.5 (95% confidence interval 1.1 to 3.1)); in people aged 15-39 the incidence was 3.2/100 person years. Incidence was highest in men and women aged 20-24 (9.2/100 person years (3.9) and 6.8/100 person years (2.9) respectively). Risk factors significantly associated with seroconversion were age 24 and under and two or more sexual partners. Between the surveys the proportion of all respondents reporting high risk behaviour (two or more partners) significantly increased from 8.9% to 12.3%. CONCLUSIONS: Despite preventive programmes and substantial knowledge about AIDS the incidence of HIV infection remains high in this rural population. Prevention aimed at vulnerable rural communities is urgently needed to contain the HIV epidemic.

PIP: In 1990, researchers followed up on as many of the 1292 adults they surveyed in 1989 as they who lived in rural Rakai district in southwestern Uganda to determine HIV-1 incidence and the risk factors associated with seroconversion. They were only able to follow up on 774 of the 1037 adults who were HIV-1 seronegative in 1989. In 1989, knowledge about AIDS and about sexual intercourse as a mode of HIV transmission was high (94% and 86%, respectively). The 1989 HIV-1 seroprevalence rate ranged from 38.5% in trading centers to 8.6% in agricultural villages off main and secondary roads. 21 (2.7%) had seroconverted (incidence = 2.1/100 person years). Since the researchers oversampled in trading centers, they estimated the weighted seroincidence to be 1.9%. HIV-1 seroconversion peaked in the 20-24 year old age group with it being greater in men than in women (9.2% vs. 6.8%). The most significant risk factor for seroconversion was number of sexual partners (8.3% for 2 or more partners vs. 2.5% for 0-1 partners; rate ratio = 3.4; p .01 for trend). The risk of seroconversion for someone with just 1 sexual partner was high (2.8%), reflecting the high HIV-1 seroprevalence in Rakai district. The percentage of subjects with at least 2 sexual partners rose from 8.9% in 1989 to 12.3% in 1990. Seroconversion was not associated with injections. No one had had a blood transfusion. Attendance at a 1989 AIDS education rally did not affect HIV seroconversion. In fact, it was greater among people attending the rally (3.5% vs. 2.1%). Logistic regression revealed that age and numbers of partners were the only significant factors affecting seroconversion (odds ration [OR] for 15-24 years compared to 25-39 years was 3.9 and OR for 2 or more sexual partners was 6.5). These findings indicated that existing HIV/AIDS education programs do not reduce HIV transmission and that better strategies are needed.

The effect of AIDS on manpower resource development in Uganda

A restrospective investigation of mortality among Uganda's highly trained manpower was carried out in 1990. It was found that the mortality rate in this category had increased from 0.4per year during the pre-AIDS period to 2.5per year by 1990. This increase was largely attributable to AIDS. These findings show that AIDS is causing big losses in training investment in Uganda