Sarah Ssali

Voluntary HIV counselling and testing among men in rural western Uganda: Implications for HIV prevention

BackgroundVoluntary HIV counselling and testing (VCT) is one of the key strategies in the prevention and control of HIV/AIDS in Uganda. However, the utilization of VCT services particularly among men is low in Kasese district. We therefore conducted a study to determine the prevalence and factors associated with VCT use among men in Bukonzo West health sub-district, Kasese district.MethodsA population-based cross-sectional study employing both quantitative and qualitative techniques of data collection was conducted between January and April 2005. Using cluster sampling, 780 men aged 18 years and above, residing in Bukonzo West health sub-district, were sampled from 38 randomly selected clusters. Data was collected on VCT use and independent variables. Focus group discussions (4) and key informant interviews (10) were also conducted. Binary logistic regression was performed to determine the predictors of VCT use among men.ResultsOverall VCT use among men was 23.3% (95% CI 17.2–29.4). Forty six percent (95% CI 40.8–51.2) had pre-test counselling and 25.9% (95%CI 19.9–31.9) had HIV testing. Of those who tested, 96% returned for post-test counselling and received HIV results. VCT use was higher among men aged 35 years and below (OR = 2.69, 95%CI 1.77–4.07), the non-subsistence farmers (OR = 2.37, 95%CI 2.37), the couple testing (OR = 2.37, 95%CI 1.02–8.83) and men with intention to disclose HIV test results to sexual partners (OR = 1.64, 95%CI 1.04–2.60). The major barriers to VCT use among men were poor utilization of VCT services due to poor access, stigma and confidentiality of services.ConclusionVCT use among men in Bukonzo West, Kasese district was low. In order to increase VCT use among men, the VCT programme needs to address HIV stigma and improve access and confidentiality of VCT services. Among the more promising interventions are the use of routine counselling and testing for HIV of patients seeking health care in health units, home based VCT programmes, and mainstreaming of HIV counselling and testing services in community development programmes.

Reasons for Disclosure of HIV Status by People Living with HIV/AIDS and in HIV Care in Uganda: An Exploratory Study

Most studies of HIV disclosure in Africa have focused on disclosure to spouses and sexual partners, and particularly among women. Few have examined disclosure to family, friends, and others. Understanding the reasons for disclosure and nondisclosure and how these reasons differ by disclosure target is needed for effective prevention interventions. Using a case study design and content analysis, this study explored whether the reasons for disclosure decisions differ by the nature of the relationship to the disclosure target. Semistructured interviews were conducted with 40 HIV clients in Kampala, with even stratification by gender and age. Most (95%) respondents reported disclosing to someone; among these, 84% disclosed to family members, 63% to friends, 21% to workplace colleagues, and 18% to others. Of the 24 participants who had a spouse, 13 (54%) reported disclosing to a spouse. The most common reasons for disclosure were to receive support (76%), associated with disclosure to family members; relationship ties (76%), associated with disclosure to all target types; explaining change in behavior or appearance (61%), associated with disclosing to family and friends; and HIV prevention (50%), associated with disclosure to spouse/partner and friends. The most common reasons for nondisclosure were: fear of abandonment, particularly among young women disclosing to spouse/partner; inaccessibility to the disclosure target; and not wanting to worry/upset the disclosure target. This exploratory analysis suggests that reasons for disclosure and nondisclosure differ depending on the targets of disclosure, highlighting the need for tailoring interventions for improving disclosure decisions making and outcomes.

Performance of community health workers under integrated community case management of childhood illnesses in eastern Uganda

BackgroundCurative interventions delivered by community health workers (CHWs) were introduced to increase access to health services for children less than five years and have previously targeted single illnesses. However, CHWs in the integrated community case management of childhood illnesses strategy adopted in Uganda in 2010 will manage multiple illnesses. There is little documentation about the performance of CHWs in the management of multiple illnesses. This study compared the performance of CHWs managing malaria and pneumonia with performance of CHWs managing malaria alone in eastern Uganda and the factors influencing performance.MethodsA mixed methods study was conducted among 125 CHWs providing either dual malaria and pneumonia management or malaria management alone for children aged four to 59 months. Performance was assessed using knowledge tests, case scenarios of sick children, review of CHWs’ registers, and observation of CHWs in the dual management arm assessing respiratory symptoms. Four focus group discussions with CHWs were also conducted.ResultsCHWs in the dual- and single-illness management arms had similar performance with respect to: overall knowledge of malaria (dual 72%, single 70%); eliciting malaria signs and symptoms (50% in both groups); prescribing anti-malarials based on case scenarios (82% dual, 80% single); and correct prescription of anti-malarials from record reviews (dual 99%, single 100%). In the dual-illness arm, scores for malaria and pneumonia differed on overall knowledge (72% vs 40%, p < 0.001); and correct doses of medicines from records (100% vs 96%, p < 0.001). According to records, 82% of the children with fast breathing had received an antibiotic. From observations 49% of CHWs counted respiratory rates within five breaths of the physician (gold standard) and 75% correctly classified the children. The factors perceived to influence CHWs’ performance were: community support and confidence, continued training, availability of drugs and other necessary supplies, and cooperation from formal health workers.ConclusionCHWs providing dual-illness management handled malaria cases as well as CHWs providing single-illness management, and also performed reasonably well in the management of pneumonia. With appropriate training that emphasizes pneumonia assessment, adequate supervision, and provision of drugs and necessary supplies, CHWs can provide integrated treatment for malaria and pneumonia.

Increased Use of Community Medicine Distributors and Rational Use of Drugs in Children Less than Five Years of Age in Uganda Caused by Integrated Community Case Management of Fever

We compared use of community medicine distributors (CMDs) and drug use under integrated community case management and home-based management strategies in children 6–59 months of age in eastern Uganda. A cross-sectional study with 1,095 children was nested in a cluster randomized trial with integrated community case management (CMDs treating malaria and pneumonia) as the intervention and home-based management (CMDs treating only malaria) as the control. Care-seeking from CMDs was higher in intervention areas (31%) than in control areas (22%; P = 0.01). Prompt and appropriate treatment of malaria was higher in intervention areas (18%) than in control areas (12%; P = 0.03) and among CMD users (37%) than other health providers (9%). The mean number of drugs among CMD users compared with other health providers was 1.6 versus 2.4 in intervention areas and 1.4 versus 2.3 in control areas. Use of CMDs was low. However, integrated community case management of childhood illnesses increased use of CMDs and rational drug use.

How to do (or not to do)… gender analysis in health systems research

Gender-the socially constructed roles, behaviours, activities and attributes that a given society considers appropriate for males, females and other genders-affects how people live, work and relate to each other at all levels, including in relation to the health system. Health systems research (HSR) aims to inform more strategic, effective and equitable health systems interventions, programs and policies; and the inclusion of gender analysis into HSR is a core part of that endeavour. We outline what gender analysis is and how gender analysis can be incorporated into HSR content, process and outcomes Starting with HSR content, i.e. the substantive focus of HSR, we recommend exploring whether and how gender power relations affect females and males in health systems through the use of sex disaggregated data, gender frameworks and questions. Sex disaggregation flags female-male differences or similarities that warrant further analysis; and further analysis is guided by gender frameworks and questions to understand how gender power relations are constituted and negotiated in health systems. Critical aspects of understanding gender power relations include examining who has what (access to resources); who does what (the division of labour and everyday practices); how values are defined (social norms) and who decides (rules and decision-making). Secondly, we examine gender in HSR process by reflecting on how the research process itself is imbued with power relations. We focus on data collection and analysis by reviewing who participates as respondents; when data is collected and where; who is present; who collects data and who analyses data. Thirdly, we consider gender and HSR outcomes by considering who is empowered and disempowered as a result of HSR, including the extent to which HSR outcomes progressively transform gender power relations in health systems, or at least do not further exacerbate them.

HIV/AIDS status disclosure increases support, behavioural change and, HIV prevention in the long term: a case for an Urban Clinic, Kampala, Uganda.

BackgroundDisclosure of HIV status supports risk reduction and facilitates access to prevention and care services, but can be inhibited by the fear of negative repercussions. We explored the short and long-term outcomes of disclosure among clients attending an urban HIV clinic in Uganda.MethodsQualitative semi-structured interviews were administered to a purposeful sample of 40 adult HIV clients that was stratified by gender. The information elicited included their lived experiences and outcomes of disclosure in the short and long term. A text data management software (ATLAS.ti) was used for data analysis. Codes were exported to MS Excel and pivot tables, and code counts made to generate statistical data.ResultsOf the 134 short-term responses elicited during the interview regarding disclosure events, most responses were supportive including encouragement, advice and support regarding HIV care and treatment. The results show on-disclosing to spouse, there was more trust, and use of condoms for HIV prevention. Only one third were negative responses, like emotional shock and feeling of distress. The negative reactions to the spouses included rejection, shock and distress in the short term. Even then, none of these events led to drastic change such as divorce. Other responses reflected HIV prevention and call for behavioural change and advice to change sexual behaviour, recipient seeking HIV testing or care. Women reported more responses of encouragement compared to men. Men reported more preventive behaviour compared to women. Of the 137 long-term outcomes elicited during disclosure, three quarters were positive followed by behavioral change and prevention, and then negative responses. Men reported increased care and support when they disclosed to fellow men compared to when women disclosed to women. There was better or not change in relationship when women disclosed to women than when women disclosed to men.ConclusionsThere is overwhelming support to individuals that disclose their HIV status, especially in the long term. Besides, gender appears to influence responses to HIV disclosure, highlighting the need for gender specific disclosure support strategies.

Social networks of PLHA in Uganda: implications for mobilizing PLHA as agents for prevention.

The objective of this study was to describe the social networks of people living with HIV/AIDS (PLHA) and explore the implications social network characteristics might have for mobilizing PLHA as prevention agents. Thirty-nine PLHA attending an HIV clinic in Kampala, Uganda provided information on themselves and on 20 network members. Based on these data, descriptive statistics for social network composition and structure were calculated. Research questions relating these network characteristics to treatment-related variables such as time since diagnosis, ART status, and time on ART were investigated. Analyses reveal that, in general, network members know the PLHA’s status, are trusted, provide advice and support, and are well-connected to each other. Network features (e.g., proportion of individuals who know the PLHA’s status) are related to the previously mentioned treatment variables. Findings suggest that PLHA surround themselves with a social context that enables PLHA to feel fairly protected and supported if they choose to discuss HIV and prevention. With respect to treatment, those on ART may be better prepared to act as prevention advocates.

Using life histories to explore gendered experiences of conflict in Gulu District, northern Uganda: Implications for post-conflict health reconstruction

ABSTRACT The dearth of knowledge about what life was like for different women and men, communities and institutions during conflict has caused many post-conflict developers to undertake reconstruction using standardised models that may not always reflect the realities of the affected populations. There is a need to engage with and understand the life experiences, transformations and social concerns of people affected by conflict before, during and after the conflict in order to develop appropriate and context embedded post-conflict reconstruction strategies. This article discusses how life histories were deployed to explore how the 20-year conflict in northern Uganda transformed peoples lives. It presents how 47 men and women lived, experienced and remembered the war in northern Uganda, and the implications for health care reconstruction. By focusing on what the respondents considered major life events in their narratives of war experiences, the article shows how through using life histories, the respondents were empowered to narrate in their own voices their experiences of war; how gender and power(lessness) shaped their experiences and their ‘situatedness’ within the conflict and thereafter; and the implications this has for post-conflict health reconstruction. The life history method enabled the researchers to surmount the subjective nature of narratives of war and its after effects, permitting the researchers to construct a picture of how experiences and challenges to well-being, health and health care seeking changed through time and what needs to be done to ensure post-conflict development prioritises the multiple health care needs of those most impoverished by the war.

Ebola in the context of conflict affected states and health systems: case studies of Northern Uganda and Sierra Leone.

Ebola seems to be a particular risk in conflict affected contexts. All three of the countries most affected by the 2014-15 outbreak have a complex conflict-affected recent history. Other major outbreaks in the recent past, in Northern Uganda and in the Democratic Republic of Congo are similarly afflicted although outbreaks have also occurred in stable settings. Although the 2014-15 outbreak in West Africa has received more attention than almost any other public health issue in recent months, very little of that attention has focused on the complex interaction between conflict and its aftermath and its implications for health systems, the emergence of the disease and the success or failure in controlling it.The health systems of conflict-affected states are characterized by a series of weaknesses, some common to other low and even middle income countries, others specifically conflict-related. Added to this is the burden placed on health systems by the aggravated health problems associated with conflict. Other features of post conflict health systems are a consequence of the global institutional response.Comparing the experience of Northern Uganda and Sierra Leone in the emergence and management of Ebola outbreaks in 2000-1 and in 2014-15 respectively highlights how the various elements of these conflict affected societies came together with international agencies responses to permit the outbreak of the disease and then to successfully contain it (in Northern Uganda) or to fail to do so before a catastrophic cost had been incurred (in Sierra Leone).These case studies have implications for the types of investments in health systems that are needed to enable effective response to Ebola and other zoonotic diseases where they arise in conflict- affected settings.

HIV Clients as Agents for Prevention: A Social Network Solution.

HIV prevention efforts to date have not explored the potential for persons living with HIV to act as change agents for prevention behaviour in their social networks. Using egocentric social network analysis, this study examined the prevalence and social network correlates of prevention advocacy behaviours (discussing HIV in general; encouraging abstinence or condom use, HIV testing, and seeking HIV care) enacted by 39 HIV clients in Uganda. Participants engaged in each prevention advocacy behaviour with roughly 50–70% of the members in their network. The strongest determinant of engaging in prevention advocacy with more of ones network members was having a greater proportion of network members who knew ones HIV seropositive status, as this was associated with three of the four advocacy behaviours. These findings highlight the potential for PLHA to be key change agents for HIV prevention within their networks and the importance of HIV disclosure in facilitating prevention advocacy.