Persistence of Traditional and Emergence of New Structural Drivers and Factors for the HIV Epidemic in Rural Uganda

bioRxiv preprint doi: https://doi.org/10.1101/516054; this version posted January 9, 2019. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 1 Persistence of traditional and emergence of new structural drivers and 2 factors for the HIV epidemic in rural Uganda; a qualitative study 3 4 5 6 Francis Bajunirwe1, Denis Akakimpa2, Flora P.Tumwebaze2, George Abongomera2 , 7 Peter N. Mugyenyi2, Cissy M. Kityo2 8 9 10 11 1. Department of Community Health, Mbarara University of Science and 12 Technology, P.O.BOX 1410, Mbarara Uganda Email: [email protected] Tel:+256 13 772 576 396 14 2. Joint Clinical Research Center, P.O.BOX 10005, Kampala, Uganda 15 16 Francis Bajunirwe, Mbarara University of Science and Technology, P.O.BOX 1410, 17 Mbarara, Uganda Email: [email protected] 18 Denis Akakimpa, Joint Clinical Research Center, P.O.BOX 10005, Kampala, Uganda 19 [email protected] 20 Flora P. Tumwebaze, Joint Clinical Research Center, P.O.BOX 10005, Kampala, Uganda 21 [email protected] 22 George Abongomera, Joint Clinical Research Center, P.O.BOX 10005, Kampala, Uganda 23 [email protected] 24 Peter N. Mugyenyi, Joint Clinical Research Center, P.O.BOX 10005, Kampala, Uganda 25 [email protected] 26 Cissy M. Kityo, Joint Clinical Research Center, P.O.BOX 10005, Kampala, Uganda 27 [email protected] 28 29 30 31 32 Corresponding author: 33 Francis Bajunirwe 34 Department of Community Health 35 P/O. BOX 1410, Mbarara, Uganda 36 Email: [email protected] Tel: +256 772 576 396 37 38 39 Key words: Structural drivers, HIV incidence, rural settings, Uganda 1 bioRxiv preprint doi: https://doi.org/10.1101/516054; this version posted January 9, 2019. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 40 Abstract 41 42 Background 43 In Uganda, the HIV epidemic is now mature and generalized. Recently, there have been 44 reports of resurgence in the incidence of HIV after several years of successful control. 45 The causes for this resurgence are not clear but suspected to be driven by structural 46 factors that influence large groups of people rather than individuals. The aim of this study 47 was to describe the structural drivers of the HIV epidemic and inform the next generation 48 of interventions. 49 50 Methodology 51 We conducted a total of 35 focus group discussions in 11 districts in Uganda. Focus 52 groups consisted of men and women including opinion leaders, civil servants including 53 teachers, police officers, religious, political leaders, shop keepers, local residents and 54 other ordinary persons from all walks of life. The qualitative data were transcribed and 55 analyzed manually. Texts were coded using a coding scheme which was prepared ahead 56 of time but emerging themes and codes were also allowed. 57 58 Results 59 Our data indicated there is persistence of several structural drivers and factors for HIV in 60 rural Uganda. The structural drivers of HIV were divided into three categories: Gender 61 issues, socio-cultural, and economic drivers. The specific drivers included several gender 62 issues, stigma surrounding illness, traditional medical practices, urbanization, alcohol and 63 substance abuse and poverty. New drivers arising from urbanization, easy access to 64 mobile phone, internet and technological advancement have emerged. These drivers are 65 intertwined within an existing culture, lifestyle and the mixture is influenced by 66 modernization. 67 68 Conclusion 69 The traditional structural drivers of HIV have persisted since the emergence of the HIV 70 epidemic in Uganda and new ones have emerged. All these drivers may require combined 71 structural interventions that are culturally and locally adapted in order to tackle the 72 resurgence in incidence of HIV in Uganda. 73 74 Key words: Structural drivers, HIV, rural settings, Uganda 2 bioRxiv preprint doi: https://doi.org/10.1101/516054; this version posted January 9, 2019. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 75 Background 76 The HIV epidemic in Uganda and many countries in sub Saharan Africa is now mature 77 and generalized. In the late 1980’s and early 1990’s, Uganda experienced a sharp 78 increase in the incidence of HIV cases, but due to several concerted prevention efforts, 79 followed by behavior change, HIV incidence reduced significantly [1-3]. Uganda was the 80 first country to register success in reducing number of new cases of HIV. However, the 81 fortunes reversed and studies started to show that HIV incidence was no longer falling 82 [4]. Studies show the incidence is in fact very high in some groups such as fishing 83 populations [5, 6], which spills over into the general population [7]. The factors 84 responsible for this negative trend are poorly understood. 85 86 The potential reasons for this resurgence in HIV incidence may due to structural factors 87 and drivers, which are typically not amenable to individual level interventions [8]. 88 Structural factors and drivers for HIV may be collectively defined as elements, other than 89 knowledge or awareness that influence risk and vulnerability to HIV infection, though 90 drivers specifically refer to a situation where an empirical association within a target 91 group has been established [9]. There is evidence that levels of knowledge on HIV are 92 generally high among countries with high HIV burden , but despite this, structural 93 factors, which are complex and entrenched in the moral, social and cultural fabric of 94 society strongly influence sexual behavior [10-12], often disregarding associated risk of 95 HIV acquisition. These structural drivers and factors have also been broadly defined by 96 some authors as “core social processes and arrangements, reflective of social and cultural 97 norms, values, networks, structures and institutions” [13]. Uganda has had several years 98 of HIV prevention programs, however anecdotal evidence suggests structural drivers and 99 factors for HIV transmission have persisted. 100 101 Widow cleansing and inheritance [14-18], and stigma [19, 20] have been well 102 documented as drivers for HIV transmission While these and other drivers are well 103 known, it is not clear if they have persisted and may therefore be potentially responsible 104 for the rise in incidence of HIV in Uganda. In this regard, they have not been well 105 characterized in this resurgence of the epidemic. More studies need to be done to identify 106 and characterize these factors and drivers, and inform the design HIV prevention 107 approaches that target them. Typically, these factors are difficult to tackle, require wider 108 scale community engagement. Interventions at individual level in this instance may not 109 be beneficial, and instead more complex approaches to delivering interventions are 110 required. Therefore, a thorough understanding of these factors is important. 111 112 To design interventions targeting these structural factors, researchers and policy makers 113 also need to understand the challenges faced in addressing these drivers. The information 114 will be used to design culturally sensitive interventions. Therefore, the aim of this study 115 was to determine the structural drivers of HIV transmission in rural Uganda and the 116 potential challenges in addressing these drivers. 117 118 119 120 3 bioRxiv preprint doi: https://doi.org/10.1101/516054; this version posted January 9, 2019. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 121 Methodology 122 Data collection 123 We conducted a total of 35 focus group discussions (FGDs) in 11 districts in northern, 124 eastern and central Uganda. We designed an FGD guide to identify structural drivers of 125 the HIV epidemic, but also to explore the extent of the already known factors. The FGDs 126 comprised of 8-12 community members and leaders, who were considered to have some 127 knowledge on societal issues related to HIV prevention and transmission. The FGDs 128 were organized along the lines of members that comprised men and women including 129 local council leaders, opinion leaders, civil servants such as teachers and police officers, 130 shop keepers, elders and village residents. Research assistants made contact with 131 potential study participants and made appointments for the FGDs to be conducted at a 132 local meeting point such as office, classroom or community center. The FGDs were 133 conducted in English for the educated class (civil servants, teachers, police officers 134 among others) and local language among less or non educated community members. On 135 average, the FGDs lasted one hour. Transport reimbursement of the equivalent of 3 USD 136 was given to the participants. The transcripts conducted in local language were translated 137 into English. 138 139 Data were collected in 11 districts that were implementing the Strengthening Civil 140 Society for Improved HIV/AIDS (SCIPHA) and Orphans and Vulnerable children (OVC) 141 service delivery project. The Joint Clinical Research Center implemented the SCIPHA 142 project with funding from Civil Society Fund. The SCIPHA was a 5-year project 143 designed to increase access and utilization of HIV/AIDS care, treatment and support 144 services and at the same time build capacity for Civil Society Organizations to deliver 145 quality HIV prevention, care and treatment services.

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