Sanyukta Mathur

Behavioral, biological, and demographic risk and protective factors for new HIV infections among youth in Rakai, Uganda.

Background:Prevalence of HIV infection is considerable among youth, although data on risk factors for new (incident) infections are limited. We examined incidence of HIV infection and risk and protective factors among youth in rural Uganda, including the role of gender and social transitions. Methods:Participants were sexually experienced youth (15–24 years old) enrolled in the Rakai Community Cohort Study, 1999–2008 (n = 6741). Poisson regression with robust standard errors was used to estimate incident rate ratios (IRR) and 95% confidence intervals (CI) of incident HIV infection. Results:HIV incidence was greater among young women than young men (14.1 vs. 8.3 per 1000 person-years, respectively); this gender disparity was greater among teenagers (14.9 vs. 3.6). Beyond behavioral (multiple partners and concurrency) and biological factors (sexually transmitted infection symptoms), social transitions such as marriage and staying in school influenced HIV risk. In multivariate analyses among women, HIV incidence was associated with living in a trading village (adjusted IRR (aIRR) = 1.48; 95% CI: 1.04 to 2.11), being a student (aIRR = 0.22; 95% CI: 0.07 to 0.72), current marriage (aIRR = 0.55; 95% CI: 0.37 to 0.81), former marriage (aIRR = 1.73; 95% CI: 1.01 to 2.96), having multiple partners, and sexually transmitted infection symptoms. Among men, new infections were associated with former marriage (aIRR = 5.57; 95% CI: 2.51 to 12.36), genital ulceration (aIRR = 3.56; 95% CI: 1.97 to 6.41), and alcohol use (aIRR = 2.08; 95% CI: 1.15 to 3.77). Conclusions:During the third decade of the HIV epidemic in Uganda, HIV incidence remains considerable among youth, with young women particularly at risk. The risk for new infections was strongly shaped by social transitions such as leaving school, entrance into marriage, and marital dissolution; the impact of marriage was different for young men than women.

Importance of Relationship Context in HIV Transmission: Results From a Qualitative Case-Control Study in Rakai, Uganda

We present results from life history interviews with 60 young adults from southern Uganda. Using a novel qualitative case-control design, we compared newly HIV-positive cases with HIV-negative controls matched on age, gender, marital status, and place of residence. Relationship context was the most salient theme differentiating cases from controls. Compared with HIV-negative respondents, recent seroconverters described relationships marked by poorer communication, greater suspicion and mistrust, and larger and more transitory sexual networks. Results highlight the importance of dyadic approaches to HIV and possibly of couple-based interventions. Using HIV-matched pairs allowed additional understanding of the factors influencing transmission. This hybrid methodological approach holds promise for future studies of sexual health.

Trends in HIV acquisition, risk factors and prevention policies among youth in Uganda, 1999-2011.

Objective:The objective of this study is to understand how trends in HIV acquisition among youth can be influenced by change in HIV risk factors, social factors and prevention and treatment programmes. Design:Trends in HIV incidence (per 1000 person-years), by sex and age group, were estimated using data from youth (15–24 years: n = 22 164) in the Rakai Community Cohort Study. Trends in HIV incidence were compared with trends in previously identified HIV risk factors, social factors and programmes. Methods:Poisson and linear regression were used to test for statistical significance and decomposition was used to calculate attribution of risk factors to HIV incidence. Results:Substantial declines between 1999 and 2011 occurred in sexual experience, multiple partners and sexual concurrency among adolescents and young adults. HIV acquisition declined substantially (86%, P = 0.006) among adolescent women (15–19 years) but not among men or young adult women. Changes in HIV incidence and risk behaviours coincided with increases in school enrolment, decline in adolescent marriage, availability of antiretroviral therapy (ART) and increases in male medical circumcision (MMC). Much of the decline in HIV incidence among adolescent women (71%) was attributable to reduced sexual experience; the decline in sexual experience was primarily attributable to increasing levels of school enrolment. Conclusion:Dramatic decreases in HIV incidence occurred among adolescent women in Rakai. Changes in school enrolment and sexual experience were primarily responsible for declining HIV acquisition over time among adolescent women. Given limited improvement among young men and young adult women, the need for effective HIV prevention for young people remains critical.

Mobility among youth in Rakai, Uganda: Trends, characteristics, and associations with behavioural risk factors for HIV

ABSTRACT Mobility, including migration and travel, influences risk of HIV. This study examined time trends and characteristics among mobile youth (15–24 years) in rural Uganda, and the relationship between mobility and risk factors for HIV. We used data from an annual household census and population-based cohort study in the Rakai district, Uganda. Data on in-migration and out-migration were collected among youth (15–24 years) from 43 communities from 1999 to 2011 (N = 112,117 observations) and travel among youth residents from 2003 to 2008 (N = 18,318 observations). Migration and travel were more common among young women than young men. One in five youth reported out-migration. Over time, out-migration increased among youth and in-migration remained largely stable. Primary reasons for migration included work, living with friends or family, and marriage. Recent travel within Uganda was common and increased slightly over time in teen women (15–19 years old), and young adult men and women (20–24 years old). Mobile youth were more likely to report HIV-risk behaviours including: alcohol use, sexual experience, multiple partners, and inconsistent condom use. Our findings suggest that among rural Ugandan youth, mobility is increasingly common and associated with HIV-risk factors. Knowledge of patterns and characteristics of a young, high-risk mobile population has important implications for HIV interventions.

Fatherhood, marriage and HIV risk among young men in rural Uganda.

Abstract Compared to a large body of work on how gender may affect young women’s vulnerability to HIV, we know little about how masculine ideals and practices relating to marriage and fertility desires shape young men’s HIV risk. Using life-history interview data with 30 HIV-positive and HIV-negative young men aged 15–24 years, this analysis offers an in-depth perspective on young men’s transition through adolescence, the desire for fatherhood and experience of sexual partnerships in rural Uganda. Young men consistently reported the desire for fatherhood as a cornerstone of masculinity and transition to adulthood. Ideally young men wanted children within socially sanctioned unions. Yet, most young men were unable to realise their marital intentions. Gendered expectations to be economic providers combined with structural constraints, such as limited access to educational and income-generating opportunities, led some young men to engage in a variety of HIV-risk behaviours. Multiple partnerships and limited condom use were at times an attempt by some young men to attain some part of their aspirations related to fatherhood and marriage. Our findings suggest that young men possess relationship and parenthood aspirations that – in an environment of economic scarcity – may influence HIV-related risk.

Partner Characteristics Associated With HIV Acquisition Among Youth in Rakai, Uganda.

Background:HIV risk is influenced by multiple factors including the behaviors and characteristics of sexual partners. We examined the association between partner characteristics and HIV acquisition among young people in rural Uganda, controlling for individual-level risk factors. Methods:We used self-reported data from 15- to 24-year-olds (n = 1969 male participants and n = 2826 female participants) from a population-based cohort (2005–2011) in Rakai, Uganda. Respondents could report characteristics for up to 4 sexual partners in the last year. Poisson regression was used to estimate HIV incidence rate ratios (IRRs). Results:In regression analyses controlling for marital status, young womens risk of HIV acquisition increased if their partner was a truck driver, drank alcohol before sex, and used condoms inconsistently. In young men, the risk of HIV acquisition increased with partners who were not enrolled in school, in partnerships with higher coital frequency, and in partnerships where respondents were unable to assess the HIV risk of their partner. Mixed-model regressions adjusting for respondents individual-level risk factors showed that young womens risk of HIV acquisition increased with each nonmarital sexual partner [IRR: 1.54 (1.20 to 1.98)], each partner who drank alcohol before sex [IRR: 1.60 (1.11 to 2.32)], and each partner who used condoms inconsistently [IRR: 1.99 (1.33 to 2.98)]. Among young men, having nonmarital partnerships increased HIV acquisition [IRR for each partner: 1.54 (1.20 to 1.98)]. Implications:Partner characteristics predicted HIV acquisition among youth. HIV prevention programs should emphasize awareness of partners risk characteristics to avoid high-risk relationships.

Public discourse on HIV and AIDS: an archival analysis of national newspaper reporting in Uganda, 1996-2011

Uganda is recognised as an early success story in the HIV epidemic at least in part due to an open and vigorous national dialogue about HIV prevention. This study examined the national discourse about HIV, AIDS, and young people in New Vision, Ugandas leading national newspaper between 1996 and 2011, building from a previous archival analysis of New Vision reporting by Kirby (1986–1995). We examined the continuing evolution in the public discourse in Uganda, focusing on reporting about young people. An increase in reporting on HIV and AIDS occurred after 2003, as antiretroviral treatment was becoming available. While the emphasis in newspaper reporting about adults and the population at large evolved to reflect the development of new HIV treatment and prevention methods, the majority of the articles focused on young people did not change. Articles about young people continued to emphasise HIV acquisition due to early and premarital sexual activity and the need for social support services for children affected by HIV and AIDS. Articles often did not report on the complex social conditions that shape HIV-related risk among young people, or address young people who are sexually active, married, and/or HIV-infected. With HIV prevalence now increasing among young people and adults in Uganda, greater attention to HIV prevention is needed.

Desire for female sterilization among women wishing to limit births in rural Rakai, Uganda

OBJECTIVE Uganda has an unmet need for family planning of 34% and a total fertility rate of 6.2. We assessed the desire for female sterilization among sexually active women who wanted to stop childbearing in rural Rakai district, Uganda. STUDY DESIGN 7192 sexually active women enrolled in a community cohort between 2002 and 2008 were asked about fertility intentions. Those stating that they did not want another child (limiters) were asked whether they would be willing to accept female sterilization, if available. Trends in desire for sterilization were determined by chi-square test for trend, and Modified Poisson regression was used to estimate prevalence rate ratios and 95% confidence intervals of the associations between desire for sterilization and socio-demographic characteristics and HIV status. RESULTS From 2002 to 2008, the proportion of limiters dropped (from 47.2% to 43.7%; p<.01). Use of pills and injectables among limiters significantly increased, 38.9% to 50.3% (p<.0001), while use of intrauterine devices and implants declined from 3.3% to 1.7% (p<0.001). The desire for sterilization significantly increased from 54.2% to 63.1% (p<0.0001), and this was consistently higher among the HIV-positive (63.6-70.9%, p<0.01) than HIV-negative women (53.3-61.2%, p<0.0001). Factors significantly associated with the desire for sterilization included higher number of living children (>=3), being HIV-infected and having received HIV counseling and testing. CONCLUSION There is latent and growing desire for sterilization in this population. Our findings suggest a need to increase permanent contraception services for women who want to limit childbearing in this setting. IMPLICATIONS A large unmet need for permanent female contraception services exists in Uganda. Efforts to increase the method mix by increasing permanent contraception services could reduce fertility rates and undesired births.

Factors associated with incident HIV infection versus prevalent infection among youth in Rakai, Uganda

Factors associated with prevalent and incident HIV infection were compared among sexually experienced Ugandans aged 15–24. Most factors were similar. However, in women, older age and current marriage were associated with prevalent, but not incident, infection. It is important to recognize the limitations of prevalence analyses for identifying at-risk youth.

Prevention of Sexually Transmitted Infections Among Adolescents

Sexually transmitted infections (STIs), including HIV infection, can have a profound impact on adolescent sexual and reproductive health. While adolescents are a quarter of the sexually active population, they represent nearly half of all new STI cases globally. STIs have considerable impact on the morbidity and mortality for infected individual, but also their partners and children. A complex interplay of biological, behavioral, sociocultural, and ecological factors put young people at risk of STIs. This chapter discusses the global spread of STIs among adolescents, the pathogens, symptoms, and health consequences of select STIs, social and behavioral determinants of STIs, and we describe key public health approaches aimed at reducing the burden of STIs among adolescents.