Background: Sub-Saharan Africa (SSA) has the highest number of people living with HIV/AIDS, with Nigeria, South Africa, and Uganda accounting for 48% of new infections. A systematic review of the HIV burden among women engaged in sex work (WESW) in 50 low-and middle-income countries found that they had increased odds of HIV infection relative to the general female population. Social structural factors, such as the sex work environment, violence, stigma, cultural issues, and criminalization of sex work are critical in shaping sexually transmitted infection (STI)/HIV risks among WESW and their clients in Uganda. Poverty is the most commonly cited reason for involvement in sex work in SSA. Against this backdrop, this study protocol describes a randomized controlled trial (RCT) that tests the impact of adding economic empowerment to traditional HIV risk reduction (HIVRR) to reduce new incidence of STIs and HIV among WESW in Rakai and the greater Masaka regions in Uganda. Methods: This three-arm RCT will evaluate the efficacy of adding savings, financial literacy and vocational training/ mentorship to traditional HIVRR on reducing new incidence of STI infections among 990 WESW across 33 hotspots. The three arms (n = 330 each) are: 1) Control group: only HIVRR versus 2) Treatment group 1: HIVRR plus Savings plus Financial Literacy (HIVRR + S + FL); and 3) Treatment group 2: HIVRR plus S plus FL plus Vocational Skills Training and Mentorship (V) (HIVRR + S + FL + V). Data will be collected at baseline (pre-test), 6, 12, 18 and 24months post-intervention initiation. This study will use an embedded experimental mixed methods design where qualitative data will be collected post-intervention across all conditions to explore participant experiences.Discussion: When WESW have access to more capital and/or alternative forms of employment and start earning formal income outside of sex work, they may be better able to improve their skills and employability for professional advancement, thereby reducing their STI/HIV risk. The study findings may advance our understanding of how best to implement gender-specific HIV prevention globally, engaging women across the HIV treatment cascade. Further, results will provide evidence for the intervention's efficacy to reduce STIs and inform implementation sustainability, including costs and cost-effectiveness.

Background HIV stigma remains a formidable barrier to HIV treatment adherence among school-attending adolescents living with HIV, owing to high levels of HIV stigma within schools, rigid school structures and routines, lack of adherence support, and food insecurity. Thus, this protocol paper presents an evidence-informed multilevel intervention that will simultaneously address family- and school-related barriers to HIV treatment adherence and care engagement among adolescents living with HIV attending boarding schools in Uganda. Objective The proposed intervention—Multilevel Suubi (MSuubi)—has the following objectives: examine the impact of M-Suubi on HIV viral suppression (primary outcome) and adherence to HIV treatment, including keeping appointments, pharmacy refills, pill counts, and retention in care; examine the effect of M-Suubi on HIV stigma (internalized, anticipated, and enacted), with secondary analyses to explore hypothesized mechanisms of change (eg, depression) and intervention mediation; assess the cost and cost-effectiveness of each intervention condition; and qualitatively examine participants’ experiences with HIV stigma, HIV treatment adherence, and intervention and educators’ attitudes toward adolescents living with HIV and experiences with group-based HIV stigma reduction for educators, and program or policy implementation after training. Methods MSuubi is a 5-year multilevel mixed methods randomized controlled trial targeting adolescents living with HIV aged 10 to 17 years enrolled in a primary or secondary school with a boarding section. This longitudinal study will use a 3-arm cluster randomized design across 42 HIV clinics in southwestern Uganda. Participants will be randomized at the clinic level to 1 of the 3 study conditions (n=14 schools; n=280 students per study arm). These include the bolstered usual care (consisting of the literature on antiretroviral therapy adherence promotion and stigma reduction), multiple family groups for HIV stigma reduction plus family economic empowerment (MFG-HIVSR plus FEE), and Group-based HIV stigma reduction for educators (GED-HIVSR). Adolescents randomized to the GED-HIVSR treatment arm will also receive the MFG-HIVSR plus FEE treatment. MSuubi will be provided for 20 months, with assessments at baseline and 12, 24, and 36 months. Results This study was funded in September 2021. Participant screening and recruitment began in April 2022, with 158 dyads enrolled as of May 2022. Dissemination of the main study findings is anticipated in 2025. Conclusions MSuubi will assess the effects of a combined intervention (family-based economic empowerment, financial literacy education, and school-based HIV stigma) on HIV stigma among adolescents living with HIV in Uganda. The results will expand our understanding of effective intervention strategies for reducing stigma among HIV-infected and noninfected populations in Uganda and improving HIV treatment outcomes among adolescents living with HIV in sub-Saharan Africa. Trial Registration ClinicalTrials.gov NCT05307250; https://clinicaltrials.gov/ct2/show/NCT05307250 International Registered Report Identifier (IRRID) PRR1-10.2196/40101

Intimate partner violence (IPV) is a significant global public health problem that results in high social and economic costs to individuals and communities. Compared to women in the general population, women engaged in sex work (WESW) are more likely to experience physical, emotional, and sexual IPV. This study examines the correlates of IPV among young WESW with their intimate partners in Southern Uganda. We used baseline data from the Kyaterekera project, a 5 year NIH-funded longitudinal study aimed at reducing HIV risks among 542 WESW in Southern Uganda. To examine the factors associated with IPV, we fitted three separate multi-level Poisson regression models for physical, emotional, and sexual IPV, respectively. Average age was 31.4 years, and 54% of the women reported being victims of at least one form of IPV from their intimate partners. Model one assessed correlates of sexual IPV. Being married women (β = .71, 95% CI [0.24, 1.17]), divorced/separated/widowed (β = .52, [0.02, 1.02]), depressed (β = .04, [0.02, 0.05]), and having any sexually transmitted infections (STIs) (β = .58, [0.14, 1.01]) were associated with sexual IPV. Model two assessed correlates of physical IPV. Experience of childhood sexual abuse (β = .12, [0.04, 0.19]) was associated with an increase in physical IPV, and increasing age reduced its occurrence (β = −.02, [−0.04, −0.001]). Finally, model three assessed emotional IPV. Women with higher education (β = .49, [0.14, 0.85]) and symptoms of depression (β = .02, [0.001, 0.04]) had higher risks for emotional IPV. For WESW, IPV presents an additional potential pathway for HIV and STIs acquisition and transmission through a lack of negotiating power for safe sex. Efforts to reduce violence against WESW should be prioritized as a strategy for enhancing the well-being of WESW.

BACKGROUND HIV stigma remains a formidable barrier to HIV treatment adherence among adolescents living with HIV (ALHIV), contributing to low rates of medication adherence, viral suppression, and high attrition from HIV care. ALHIV in schools have lower levels of HIV treatment adherence due to high levels of HIV stigma within schools, rigid school structures and routines, lack of adherence support, and food insecurity. Thus, this paper presents a protocol for an evidence-informed multilevel intervention that will simultaneously address multiple family- and school-related barriers to HIV treatment adherence and care engagement among ALHIV attending boarding schools in Uganda. OBJECTIVE Aim 1: Examine the impact of M-Suubi on HIV viral suppression (primary outcome) and adherence to HIV treatment including keeping appointments, pharmacy refills, pill counts and retention in care Aim 2: Examine the effect of M-Suubi on HIV stigma (internalized, anticipated, and enacted), with secondary analyses to explore hypothesized mechanisms of change (e.g. depression) and intervention mediation; Aim 3: Assess the cost and cost-effectiveness of each intervention condition, and; Aim 4: Qualitatively examine: a) participants’ experiences with HIV stigma, HIV treatment adherence, and the intervention; and 2) educators’ attitudes towards ALHIV and experiences with GED-HIVSR, and program/policy implementation post-training. METHODS Study targets ALHIV aged 10 – 17 years and enrolled in a primary or secondary school with a boarding section. This longitudinal study will utilize a three-arm cluster randomized design across 42 HIV clinics in Southwestern Uganda. Participants will be randomized at clinic level to one of the 3 study conditions (n= 14 schools, n=280 students per study arm): 1) Bolstered usual care (BSOC) consisting of literature on ART adherence promotion and stigma reduction; 2) Group-based HIV stigma reduction for educators (GED-HIVSR); and 3) Multiple family groups for HIV stigma reduction plus family economic empowerment (MFG-HIVSR plus FEE) for ALHIV. For ALHIV randomized to treatment Arm 2 (i.e. MFG-HIVSR plus FEE and GED-HIVSR), we will include all the schools in the GED-HIVSR component, irrespective of the number of participants attending the school. M-Suubi will be provided for 20 months, with assessments at baseline, 12, 24, and 36 months. RESULTS The study is currently enrolling study participants. CONCLUSIONS Study findings will have important implications for HIV treatment adherence and engagement in care among ALHIV SSA. By targeting ALHIV, their caregivers, and educators, this multi-level study will generate evidence on effective intervention strategies for reducing stigma among HIV-infected and non-infected populations in Uganda and enable an ecological assessment of the cascading effects of multi-level HIV stigma reduction strategies. The study, currently recruiting study participants, would provide crucial evidence on effective and scalable strategies for addressing HIV stigma and improving HIV treatment outcomes among in-school ALHIV in resource-poor settings. CLINICALTRIAL NCT05307250