Background Prevalence of HIV infection is considerable among youth, although data on risk factors for new (incident) infections is 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 teens (14.9 vs. 3.6). Beyond behavioral (multiple partners and concurrency) and biological factors (sexually transmitted infection (STI) 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.

BackgroundLow contraceptive uptake and high unmet need for contraception remain significant issues in Uganda compared to neighboring countries such as Kenya, Ethiopia, and Rwanda. Although prior research on contraceptive uptake has indicated that male partners strongly influence women’s decisions around contraceptive use, there is limited in-depth qualitative research on knowledge and concerns regarding modern contraceptive methods among Ugandan men.MethodsUsing in-depth interviews (N = 41), this qualitative study investigated major sources of knowledge about contraception and perceptions of contraceptive side effects among married Ugandan men. RESULTS: Men primarily reported knowledge of contraceptives based on partner’s experience of side effects, partner’s knowledge from health providers and mass media campaigns, and partner’s knowledge from her peers. Men were less likely to report contraceptive knowledge from health care providers, mass media campaigns, or peers. Men’s concerns about various contraceptive methods were broadly associated with failure of the method to work properly, adverse health effects on women, and severe adverse health effects on children. Own or partner’s human immunodeficiency virus (HIV) status did not impact on contraceptive knowledge.ConclusionsOverall, we found limited accurate knowledge about contraceptive methods among men in Uganda. Moreover, fears about the side effects of modern contraceptive methods appeared to be common among men. Family planning services in Uganda could be significantly strengthened by renewed efforts to focus on men’s knowledge, fears, and misconceptions.

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 1999-2011 (N=112,117 observations) and travel among youth residents from 2003-2008 (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.

BackgroundGendered power dynamics within couple relationships can constrain women from achieving positive sexual and reproductive health outcomes. But little is known about relationship power among adolescents, and tools to measure it are rarely validated among adolescents. We tested the Sexual Relationship Power Scale (SRPS) among adolescent girls and young women (AGYW) and examined associations with select health outcomes.MethodsA 16-item adaptation of the SRPS was administered to AGYW aged 15–24 in Kenya (n = 1,101). Confirmatory factor analysis (CFA) and theta coefficients assessed scale performance for three age bands: 15–17, 18–20, and 21–24 years old. Relationship power levels were examined and multivariate logistic regressions assessed the relationship between power, and partner violence and HIV risk outcomes.ResultsCFAs confirmed a one factor structure for each subgroup, and thetas for final 15-item scales were robust (>.82). Most respondents reported limited power in their sexual relationships, however older respondents consistently reported lower levels of power. Relationship power was strongly associated with several outcomes, even when controlling for socioeconomic status and schooling. For example, AGYW who reported more relationship power were 12, 6, and 7 times less likely (ages 21–24, 18–20, and 15–17, respectively) to experience sexual violence (p<0.001). Significant relationships were also found in multivariate analyses for physical partner violence (all three age bands), using a condom at last sex (18–20-year-olds), and increased knowledge of partner’s HIV status (21–24-year-olds).ConclusionsThe SRPS is a good measure of relationship power for several age bands within AGYW, and power is experienced differently by older and younger AGYW. Low relationship power was a consistent predictor of partner violence, as well as an important predictor of HIV risk. Interventions seeking to address HIV and violence should also explicitly address relationship power and utilize validated tools (like the SRPS) to evaluate impacts.

BackgroundOral pre-exposure prophylaxis (PrEP) has the potential to reduce HIV acquisition among adolescent girls and young women (AGYW) in sub-Saharan Africa. However, health care providers’ (HCPs) perspectives and interactions with potential clients can substantially influence effective provision of quality health services. We examine if HCPs’ knowledge, attitude, and skills, as well as their perceptions of facility readiness to provide PrEP are associated with their willingness to provide PrEP to AGYW at high risk of HIV in Tanzania.MethodsA self-administered questionnaire was given to 316 HCPs from 74 clinics in two districts and 24 HCPs participated in follow-up in-depth interviews (IDIs). We conducted bivariate and multivariable Poisson regression to assess factors associated with willingness to provide PrEP to AGYW. Thematic content analysis was used to analyze the IDIs, which expanded upon the quantitative results.ResultsFew HCPs (3.5%) had prior PrEP knowledge, but once informed, 61.1% were willing to prescribe PrEP to AGYW. Higher negative attitudes toward adolescent sexuality and greater concerns about behavioral disinhibition due to PrEP use were associated with lower willingness to prescribe PrEP. Qualitatively, HCPs acknowledged that biases, rooted in cultural norms, often result in stigmatizing and discriminatory care toward AGYW, a potential barrier for PrEP provision. However, better training to provide HIV services was associated with greater willingness to prescribe PrEP.Conversely, HCPs feared the potential negative impact of PrEP on the provision of existing HIV services (e.g., overburdened staff), and suggested the integration of PrEP into non-HIV services and the use of paramedical professionals to facilitate PrEP provision.ConclusionsPreparing for PrEP introduction requires more than solely training HCPs on the clinical aspects of providing PrEP. It requires a two-pronged strategy: addressing HCPs’ biases regarding sexual health services to AGYW; and preparing the health system infrastructure for the introduction of PrEP.