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      Persistence of traditional and emergence of new structural drivers and factors for the HIV epidemic in rural Uganda; A qualitative study

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          Abstract

          Background

          In Uganda, the HIV epidemic is now mature and generalized. Recently, there have been reports of resurgence in the incidence of HIV after several years of successful control. The causes for this resurgence are not clear but suspected to be driven by structural factors that influence large groups of people rather than individuals. The aim of this study was to describe the structural drivers of the HIV epidemic in high prevalence regions and inform the next generation of interventions.

          Methodology

          We conducted a total of 35 focus group discussions in 11 districts in Uganda. Due to their high HIV prevalence, the districts had been selected to implement a donor supported program to scale up HIV prevention, care and treatment. Focus groups consisted of men and women including opinion leaders, civil servants including teachers, police officers, religious, political leaders, shop keepers, local residents and other ordinary persons from all walks of life. The qualitative data were transcribed and analyzed manually. Texts were coded using a coding scheme which was prepared ahead of time but emerging themes and codes were also allowed.

          Results

          Our data indicated there is persistence of several structural drivers and factors for HIV in rural Uganda. The structural drivers of HIV were divided into three categories: Gender issues, socio-cultural, and economic drivers. The specific drivers included several gender issues, stigma surrounding illness, traditional medical practices, urbanization, alcohol and substance abuse and poverty. New drivers arising from urbanization, easy access to mobile phone, internet and technological advancement have emerged. These drivers are intertwined within an existing culture, lifestyle and the mixture is influenced by modernization.

          Conclusion

          The traditional structural drivers of HIV have persisted since the emergence of the HIV epidemic in Uganda and new ones have emerged. All these drivers may require combined structural interventions that are culturally and locally adapted in order to tackle the resurgence in incidence of HIV in Uganda.

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          Most cited references33

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          Effectiveness of an integrated intimate partner violence and HIV prevention intervention in Rakai, Uganda: analysis of an intervention in an existing cluster randomised cohort.

          Jennifer Wagman, Ronald Gray, Jacquelyn Campbell … (2015)
          Intimate partner violence (IPV) is associated with HIV infection. We aimed to assess whether provision of a combination of IPV prevention and HIV services would reduce IPV and HIV incidence in individuals enrolled in the Rakai Community Cohort Study (RCCS), Rakai, Uganda.
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            Addressing social drivers of HIV/AIDS for the long-term response: conceptual and methodological considerations.

            Judith D Auerbach, Justin O Parkhurst, Carlos F. Caceres (2011)
            A key component of the shift from an emergency to a long-term response to AIDS is a change in focus from HIV prevention interventions focused on individuals to a comprehensive strategy in which social/structural approaches are core elements. Such approaches aim to modify social conditions by addressing key drivers of HIV vulnerability that affect the ability of individuals to protect themselves and others from HIV. The development and implementation of evidence-based social/structural interventions have been hampered by both scientific and political obstacles that have not been fully explored or redressed. This paper provides a framework, examples, and some guidance for how to conceptualise, operationalise, measure, and evaluate complex social/structural approaches to HIV prevention to help situate them more concretely in a long-term strategy to end AIDS.
            Article 0 comments Cited 106 times – based on 0 reviews     Review now
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              Changing patterns in HIV/AIDS stigma and uptake of voluntary counselling and testing services: the results of two consecutive community surveys conducted in the Western Cape, South Africa.

              Robin Wood, Keren Middelkoop, Daniella Mark … (2012)
              Voluntary counselling and HIV testing (VCT) has been associated with decreased human immunodeficiency virus (HIV) risk behaviour, but in South Africa, which has the largest HIV/acquired immune deficiency syndrome (AIDS) epidemic in the world, uptake of VCT remains low. HIV/AIDS-associated stigma has been identified as a barrier to HIV testing. This study explored changes in stigma, and VCT access in a peri-urban South African community with high HIV prevalence, following education and research interventions, as well as the introduction of a wide-scale antiretroviral therapy (ART) programme. Two cross-sectional community surveys assessing HIV knowledge, attitudes and uptake of VCT services were conducted. The first survey was performed in 2004 prior to the implementation of a community-based HIV awareness and education campaign, HIV prevention research studies and the introduction of an ART programme. The second survey was performed in 2008 after a three-year education programme, the implementation of HIV-related research studies and following the scale-up of the ART programme. The same study design was used in both the 2004 and 2008 surveys: 10% of households were randomly selected and all residents aged ≥ 14 years were invited to complete a self-administered questionnaire. Overall basic knowledge of HIV/AIDS increased from 2004 to 2008 (p=0.04) and stigmatisation towards HIV-positive individuals decreased over the same time period (p<0.001). Increasing knowledge score was significantly associated with a lower stigma score (p<0.001). Decreasing stigma score was associated with knowing someone who was HIV infected (p<0.001), or who had died from HIV/AIDS (p=0.04). The proportion of participants who had undergone HIV testing increased from 2004 to 2008 (40 vs. 70%, respectively) and, in particular, VCT increased from 26 to 43%. In adjusted analysis, participants who had undergone HIV testing were more likely to have a higher HIV knowledge score (p=0.02) and a lower stigma score (p=0.09). A reduction in levels of HIV/AIDS-associated stigma was noted in a community burdened with high HIV prevalence, as was an increase in reported VCT. These findings may be the result of a number of interventions including a wide-spread and targeted education campaign, and the "normalisation" of HIV through the availability of ART. Given the role of HIV/AIDS-associated stigma in influencing choices to access HIV testing, and the benefits associated with HIV testing, interventions to reduce stigma in communities affected by this disease should be encouraged.
              Article 0 comments Cited 51 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Francis Bajunirwe:
                ORCID: http://orcid.org/0000-0002-1326-5230
                Role: ConceptualizationRole: Formal analysisRole: MethodologyRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Denis Akakimpa: Role: ConceptualizationRole: Formal analysisRole: MethodologyRole: Writing – review & editing
                Flora P. Tumwebaze: Role: ConceptualizationRole: Formal analysisRole: Project administrationRole: SupervisionRole: Writing – review & editing
                George Abongomera: Role: Formal analysisRole: Funding acquisitionRole: MethodologyRole: Project administrationRole: Writing – review & editing
                Peter N. Mugyenyi: Role: ConceptualizationRole: Data curationRole: Funding acquisitionRole: Project administrationRole: ResourcesRole: Writing – original draftRole: Writing – review & editing
                Cissy M. Kityo: Role: ConceptualizationRole: Formal analysisRole: Funding acquisitionRole: MethodologyRole: Project administrationRole: Writing – original draftRole: Writing – review & editing
                Jerome T. Galea: Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, CA USA )
                ISSN (Electronic): 1932-6203
                Publication date (Electronic): 6 November 2019
                Publication date Collection: 2019
                Volume: 14
                Issue: 11
                Electronic Location Identifier: e0211084
                Affiliations
                [1 ] Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
                [2 ] Joint Clinical Research Center, Kampala, Uganda
                University of South Florida, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0002-1326-5230
                Article
                Publisher ID: PONE-D-18-36920
                DOI: 10.1371/journal.pone.0211084
                PMC ID: 6837848
                PubMed ID: 31693660
                SO-VID: 83ddf2a4-3468-4c01-958d-b7257517998e
                Copyright © © 2019 Bajunirwe et al
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 25 January 2019
                Date accepted : 21 October 2019
                Page count
                Figures: 1, Tables: 0, Pages: 15
                Funding
                The data collection was conducted as part of Strengthening Civil Society for Improved HIV/AIDS (SCIPHA) project funded by Civil Society Fund grant to JCRC (PI Professor Peter Mugyenyi). The funders had no role in the study design, data collection, analysis or preparation of this manuscript.
                Categories
                Subject: Research Article
                Subject: Medicine and health sciences
                Subject: Epidemiology
                Subject: HIV epidemiology
                Subject: Biology and Life Sciences
                Subject: Microbiology
                Subject: Medical Microbiology
                Subject: Microbial Pathogens
                Subject: Viral Pathogens
                Subject: Immunodeficiency Viruses
                Subject: HIV
                Subject: Medicine and Health Sciences
                Subject: Pathology and Laboratory Medicine
                Subject: Pathogens
                Subject: Microbial Pathogens
                Subject: Viral Pathogens
                Subject: Immunodeficiency Viruses
                Subject: HIV
                Subject: Biology and Life Sciences
                Subject: Organisms
                Subject: Viruses
                Subject: Viral Pathogens
                Subject: Immunodeficiency Viruses
                Subject: HIV
                Subject: Biology and Life Sciences
                Subject: Organisms
                Subject: Viruses
                Subject: Immunodeficiency Viruses
                Subject: HIV
                Subject: Biology and life sciences
                Subject: Organisms
                Subject: Viruses
                Subject: RNA viruses
                Subject: Retroviruses
                Subject: Lentivirus
                Subject: HIV
                Subject: Biology and Life Sciences
                Subject: Microbiology
                Subject: Medical Microbiology
                Subject: Microbial Pathogens
                Subject: Viral Pathogens
                Subject: Retroviruses
                Subject: Lentivirus
                Subject: HIV
                Subject: Medicine and Health Sciences
                Subject: Pathology and Laboratory Medicine
                Subject: Pathogens
                Subject: Microbial Pathogens
                Subject: Viral Pathogens
                Subject: Retroviruses
                Subject: Lentivirus
                Subject: HIV
                Subject: Biology and Life Sciences
                Subject: Organisms
                Subject: Viruses
                Subject: Viral Pathogens
                Subject: Retroviruses
                Subject: Lentivirus
                Subject: HIV
                Subject: People and Places
                Subject: Geographical Locations
                Subject: Africa
                Subject: Uganda
                Subject: Medicine and health sciences
                Subject: Public and occupational health
                Subject: Preventive medicine
                Subject: HIV prevention
                Subject: Medicine and Health Sciences
                Subject: Complementary and Alternative Medicine
                Subject: Traditional Medicine
                Subject: Medicine and health sciences
                Subject: Infectious diseases
                Subject: Viral diseases
                Subject: HIV infections
                Subject: Social Sciences
                Subject: Sociology
                Subject: Sexual and Gender Issues
                Subject: Medicine and Health Sciences
                Subject: Epidemiology
                Subject: Medical Risk Factors
                Subject: Traumatic Injury Risk Factors
                Subject: Violent Crime
                Subject: Domestic Violence
                Subject: Medicine and Health Sciences
                Subject: Public and Occupational Health
                Subject: Traumatic Injury Risk Factors
                Subject: Violent Crime
                Subject: Domestic Violence
                Subject: Social Sciences
                Subject: Sociology
                Subject: Criminology
                Subject: Crime
                Subject: Violent Crime
                Subject: Domestic Violence
                Custom metadata
                Data Availability Data and transcripts are available on request, however, given the qualitative nature of the data, there are restrictions on the distribution. There are significant identifiers in the long transcripts of data including names of places and positions of persons, which renders it difficult to edit and share. Additional permission to access the data will be obtained from the research ethics committee at Joint Clinical Research Center. Please send an email to rnamusisi@ 123456jcrc.org.ug .

                ScienceOpen disciplines: Uncategorized
                Data availability:
                ScienceOpen disciplines: Uncategorized

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