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Uganda AIDS Commission Uganda HIV/AIDS Control Project (MAP)
LQAS Monitoring Report Assessment of HIV/AIDS Related Knowledge, Practices and Coverage in 19 Districts of Uganda October-November 2003
Phyllis Joy Mukaire David Kaweesa Kisitu John B. Ssekamatte-Ssebuliba Joseph J. Valadez
June 2004
Table of Contents LIST OF ACRONYMS ...... V ACKNOWLEDGEMENTS ...... VI EXECUTIVE SUMMARY ...... 1 MAJOR FINDINGS ...... 1 FOLLOW-UP STUDY RESULTS...... 3 CHAPTER 7 REPORTS FINDINGS OF THE DIAGNOSTIC STUDY WHICH MANAGERS SHOULD CONSIDER WHEN DESIGNING STRATEGIES FOR IMPROVING OR REDIRECTING THEIR PROGRAMS.BACKGROUND ...... 3 BACKGROUND...... 4 THE MULTI-COUNTRY AIDS PROJECT ...... 4 DISTRICT VARIATIONS ...... 5 CHAPTER 1: FINDINGS FOR MEN 15-54...... 6 VOLUNTARY COUNSELING AND TESTING ...... 6 KNOWLEDGE OF MOTHER-TO-CHILD TRANSMISSION OF HIV/AIDS...... 7 KNOWLEDGE OF THE ABC’S OF HIV/AIDS PREVENTION AND KNOWLEDGE OF TREATMENT FOR STI’S ...... 8 MISCONCEPTIONS ABOUT HIV/AIDS ...... 10 SELF-ASSESSMENT OF RISK ...... 11 CONDOM USE ...... 12 CHAPTER 2: FINDINGS FOR WOMEN 15-49...... 13 VOLUNTARY COUNSELING AND TESTING ...... 13 KNOWLEDGE OF MOTHER-TO-CHILD TRANSMISSION OF HIV/AIDS...... 14 KNOWLEDGE OF THE ABC’S OF HIV/AIDS PREVENTION AND KNOWLEDGE OF TREATMENT FOR STIS...... 14 MISCONCEPTIONS ABOUT HIV/AIDS ...... 15 SELF-ASSESSMENT OF RISK ...... 16 CONDOM USE ...... 17 CHAPTER 3: FINDINGS FOR MOTHERS OF CHILDREN 0-11...... 19 KNOWLEDGE OF MOTHER-TO-CHILD TRANSMISSION OF HIV/AIDS...... 19 USE OF ANTENATAL CARE SERVICES...... 19 DELIVERY IN A HEALTH FACILITY ...... 20 COUNSELING ON MTCT AND VCT...... 21 CHAPTER 4: FINDINGS FOR YOUNG PEOPLE 15-24 ...... 22 KNOWLEDGE OF THE ABC’S OF AIDS PREVENTION ...... 22 SEXUAL BEHAVIOUR...... 23 CORRECT USE OF CONDOMS ...... 25 SELF-ASSESSMENT OF RISK AND MISCONCEPTIONS ABOUT TRANSMISSION ...... 26 KNOWLEDGE OF SEXUALLY TRANSMITTED INFECTIONS AND OF MTCT ...... 27
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CHAPTER 5: FINDINGS FOR ORPHANS 6-18...... 29 TYPES OF ORPHANS ...... 29 EDUCATION...... 30 CARE AND SUPPORT...... 32 MATERIAL SUPPORT...... 32 CHAPTER 6: FINDINGS FOR PEOPLE LIVING WITH HIV/AIDS ...... 33 A PROFILE OF PLWHAS...... 33 MEDICAL CARE FOR PLWHAS...... 34 OTHER TYPES OF CARE AND SUPPORT ...... 35 POSITIVE LIVING PRACTICES ...... 36 HARMFUL PRACTICES ...... 37 MISCONCEPTIONS ABOUT HIV/AIDS ...... 38 KNOWLEDGE OF THE ABCS OF HIV/AIDS PREVENTION AND CONDOM USE ...... 38 CHAPTER 7: FINDINGS OF THE FOLLOW-UP STUDY...... 40 PURPOSE OF THE FOLLOW-UP STUDY ...... 40 FINDINGS ...... 41 Preventing MTCT...... 41 PMTCT Facility Assessment...... 45 TYPE AND LEVEL OF FACILITY ...... 46 CONDOM USE ...... 49 VOLUNTARY COUNSELING AND TESTING ...... 56 PEOPLE LIVING WITH HIV/AIDS...... 61 PLWHA Service Facility Assessment...... 64 ORPHAN CARE AND SUPPORT ...... 67 COMMUNITY LEVEL HIV/AIDS EDUCATION AND PROMOTION...... 68 METHODS ...... 70 Study Area...... 70 Capacity to Undertake the Study ...... 70 Study Methods and Target Groups ...... 70 Facility Assessment...... 71 Key Informant Interviews...... 71 Focus Group Discussions ...... 71 Document Review...... 72 CHAPTER 8: LQAS PRINCIPLE AND METHOD...... 73 PRINCIPLES ...... 73 METHODS ...... 75 The Sample...... 75 Sampling at the District Level...... 75 SELECTING AND TRAINING INTERVIEWERS ...... 76 Training...... 77 DATA COLLECTION...... 77 DATA ANALYSIS ...... 80 OVERVIEW OF LQAS IMPLEMENTATION ...... 80
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ANNEX 1: LQAS PRINCIPLES FOR PROGRAMME MONITORING ...... 81 APPENDICES...... 84 APPENDIX A. KEY MEN’S INDICATORS BY DISTRICT...... 84 APPENDIX B. KEY WOMEN’S INDICATORS BY DISTRICT...... 91 APPENDIX C. KEY MOTHERS’ INDICATORS BY DISTRICT ...... 96 APPENDIX D. KEY YOUNG PEOPLE DISTRICT INDICATORS...... 100 APPENDIX E. KEY ORPHANS’ INDICATORS BY DISTRICT ...... 104 APPENDIX F. KEY PLWHA INDICATORS BY DISTRICT...... 106 REFERENCES...... 110
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List of Acronyms
ABC Abstinence, Be Faithful, Condom Use AIDS Acquired imuno-deficiency syndrome ANC Antenatal Care ART Antiretroviral Treatment CHAI Community HIV/AIDS Initiative CSO Civil Society Organization DHAC District HIV/AIDS Committee HIV Human Imuno-Deficiency Virus IGA income-generating activities IEC information, education, and counseling GAMET Global AIDS Monitoring and Evaluation Support Team LQAS Lot Quality Assurance Sampling or Local Quality Assurance and Supervision M&E monitoring and evaluation MAP Multi-country AIDS Project MIS management information system MTCT mother-to-child transmission NGO nongovernmental organization NSF National Strategic Framework OVC orphans and vulnerable children PCT project coordination team PLWHA people living with HIV/AIDS PMTCT prevention of mother-to-child transmission STD sexually transmitted disease TASO The AIDS Support Organization TRN technical regional network UAC Uganda AIDS Commission UACP Uganda AIDS Control Project UNGASS United Nations General Assembly VCT voluntary counseling and testing
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Acknowledgements
The Uganda LQAS survey, implemented by the UAC in 19 districts, was the first of its kind in Uganda. The major objective of the LQAS survey was to build monitoring and evaluation capacity at the district and community levels and to assess the HIV/AIDS programme at those levels. The results of the survey have enabled local managers to not only know the current status of their programmes but also to make management decisions about how to improve them. Used regularly, LQAS will enable managers to continuously review and make management decisions to improve their programme strategies. At the same time the survey results will be used for national and global reporting.
The UAC and management of the UACP would like to thank the many people were responsible for the successful completion of this effort.
Special thanks to DHAC members, CSOs, and other implementers at the county level (under the leadership of the District HIV/AIDS Focal Persons in the 19 districts) for mobilising communities, collecting data, and hand-tabulating their respective district results. We thank the PLWHAs for their active participation in collecting and analysing data, and the local leaders, particularly those at the village level, who coordinated the data collection in their respective villages. Special gratitude also goes to all the respondents for investing their valuable time in this work.
The TRN members provided valuable back-up support to UACP in planning and implementing the survey. The contribution of the following UACP Regional Project Officers was instrumental in the planning and implementation of the survey: Peter Cwinya-ai, Catherine Muwanga, Mayanja S.P, and Ssinabulya Mwanje. In addition, the IEC Specialist Lillian Nakato and the CHIA Specialist Steven Kiirya contributed greatly to the success of the survey. Special thanks go to the MIS officer, Charles Nkolo, who in addition to helping plan and implement the survey also coordinated and managed the data entry. The Project Management also provided valuable technical support and guidance, and the administrative and support staff at UACP and in the districts worked especially hard.
We also acknowledge the Uganda Bureau of Statistics for providing sampling frames and maps, the Institute of Statistics and Applied Economics at Makerere University for providing technical and expert advice to the survey team, the Uganda Community Based Care Health Association for generating the household lists, and the AIM and UPHOLD projects for their partnership in implementing the survey.
The UAC is likewise grateful for the support of the Ministry of Health for their expert advice on programme indicators and on the survey design. The UAC technical team also provided valuable support and guidance. The technical support provided by the Global AIDS Monitoring and Evaluation Support Team (GAMET) of The World Bank was critical in undertaking the survey. GAMET’s technical support has contributed greatly to building the capacity for monitoring and evaluating HIV/AIDS activities in the country and is very much appreciated. At The World Bank, Shiyan Chou, Son Nam Nguyen. Peter Okwero, Susan Stout, and Yoko Shimada played essential roles in this activity.
The Uganda AIDS Control Project, July 2004
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Executive Summary
Reducing the prevalence of HIV/AIDS is an urgent priority for the government of Uganda and is defined in the National Strategic Framework (NSF) 200/1 –2005/6. The leading programme in the fight against HIV/AIDS is the Multi-country AIDS Project (MAP), a set of interventions funded by The World Bank. MAP was designed to support the operationalization of the NSF specifically meant to scale up the national response. In early 2004, the MAP initiative in Uganda will undergo a mid-term review, and in preparation for that review the Uganda AIDS Control Project (which implements MAP) has conducted an assessment of the initiative in 19 districts (listed in the Appendices), with the help of the World Bank’s Global AIDS Monitoring and Evaluation Support Team (GAMET).
The assessment measured:
The knowledge and perceptions of men 15-54, women 15-49, and youth 15-24 of: o HIV/AIDS o Sexually transmitted disease prevention o The role of voluntary counseling and testing (VCT) in HIV/AIDS prevention o Preventing mother-to-child transmission of HIV/AIDS o HIV/AIDS-related services in their community
PMTCT and STD practices among mothers of children 0-11 months HIV/AIDS prevention practices among men, women, and youth The adequacy of care and support services for orphans (6-18 years), and for people living with HIV/AIDS (PLWHAs).
Major Findings
The major findings of this assessment will be used by district programme staff to evaluate the impact of their efforts to date and make appropriate changes to their strategies, priorities, and allocations of resources. A selection of the findings for each group is presented below, along with brief commentary. Percentage decimals have been rounded.
Please note that these results should not be compared with the results of the 2001 Uganda DHS. The principal reasons for this are that: (1) this study includes only 19 districts whereas the DHS includes all districts; and (2) the age ranges of some of the populations differ (e.g., mothers of infants 0-11 months in this survey as opposed to mothers of children under 5 years of age in the DHS survey). . Men 15-54 Years
Men who knew at least two of the benefits of VCT: 47 per cent Men who had taken an HIV test: 14 per cent Men who knew of the risk of MTCT: 80 per cent Men who had sex with a non-regular partner in the last 12 months: 24 per cent Men who had ever used a condom: 51 per cent
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A striking conclusion from the findings among men is an apparent disconnect between knowledge and behaviour. While nearly half of men (47 per cent) knew at least two of the benefits of voluntary counseling and testing, only 14 per cent had actually taken an HIV test. In a similar finding, 64 per cent knew two or more of the ABCs of prevention but just over half of men (51 per cent) said they had ever used a condom. The disconnect aside, it should be a matter of some concern that 86 per cent of the men in Uganda have apparently not had an HIV test and that half the men have never used a condom.
Women 15-49 Years
Women who knew at least two of the benefits of VCT: 39 per cent Women who had taken an HIV test: 14 per cent Women who knew of the risk of MTCT: 78 per cent Women who had sex with a non-regular partner in the last 12 months: 9 per cent Women who had ever used a condom: 31 per cent
Women were also much more likely to be aware of the benefits of VCT (39 per cent) than to have acted on this information and actually taken a test (14 per cent). Women were almost three times less likely than men to have had casual sex (sex with a non-regular partner in the last 12 months), but they were also less likely to have used a condom during sex (31% per cent. More women than men may be having unprotected sex, a risk factor for HIV/AIDS, but fewer are having casual sex (another risk factor). Four fifths of all men and women knew the risk of MTCT.
Mothers of Children 0-11 Months
Mothers who attended an antenatal care clinic: 80 per cent Mothers who knew the risk of MTCT: 81 per cent Mothers who were counseled to take an HIV test: 38 per cent Mothers who took an HIV test: 13 per cent Mothers who delivered in a health facility: 51 per cent Mothers who delivered at home: 49 per cent
Mothers were well aware of the risk of MTCT. It is disappointing that just over one third of mothers were counseled about HIV and only 13% (the same per cent as men) had taken a test. ANC centres appear to be missing an opportunity to counsel women about VCT. Nearly half of mothers delivered in a health facility, which usually reduces the risk of MTCT during labour and delivery.
Young People 15-24 Years
Young people who knew at least two of the ABCs: 52 per cent Median age of first sexual intercourse: 17 years Young people who always use a condom: 26 per cent Young people who know how to use a condom correctly: 30 per cent
Young people appear to be taking risks in their sexual behaviour, in spite of more than half knowing at least two of the ways to protect themselves.
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Orphans 6-18 Years
Orphans in school: 82 per cent Orphans in school who attended 5 days of class in the preceding week: 71.6 per cent Receiving support: Educational 15 per cent Psychosocial 10 per cent Material 3 per cent
It is encouraging that four fifths of orphans are in school, and that 73 per cent of school attendees went to school five days in the week preceding the survey. However, only a small percentage of orphans are getting any kind of support.
People Living with HIV/AIDS
PLWHAs who received medical care if needed: 94 per cent PLWHAs who joined a support organization/group: 68 per cent PLWHAs who always use a condom: 49 per cent Sexually active PLWHA who never use a condom: 23 per cent
Condom use by gender: Men who always use 33 per cent Women who always use 67 per cent
PLWHAs appear to have access to medical care. It is also encouraging that two thirds have joined a support group. Male condom use is low for people who should know the risk.
Follow-up Study Results
The assessment raised as many questions as it answered, especially in the area of the breakdown between what people knew about HIV/AIDS and its risks and their own sexual behaviour. A follow-up study section (chapter 7) addresses some of the more urgent questions, specifically:
readiness of locations or sites designated to provide PMTCT reasons behind the low use of condoms among women and young people what motivates women, men and young people to use VCT and what are the impediments why only a few orphans are reached in those districts where orphan care and support interventions have been tried why PLWHAs do not embrace safer sex practices despite exposure to positive living counseling
Chapter 7 reports findings of the diagnostic study which managers should consider when designing strategies for improving or redirecting their programs.
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Background
Fighting the HIV/AIDS epidemic has become an urgent national priority for the government of Uganda and is in fact one of the key components of the national Poverty Eradication Action Plan. The goals of the national response to the AIDS epidemic, as set out in the National Strategic Framework for HIV/AIDS Activities in Uganda, are:
1. To reduce HIV prevalence by 25 per cent 2. To mitigate the effects of HIV/AIDS, specifically:
To mitigate the health effects of HIV/AIDS and improve the quality of life of people living with AIDS To mitigate the psychosocial and economic effects of HIV/AIDS To mitigate the impact of HIV/AIDS on the development of Uganda
3. To strengthen the national capacity to coordinate and manage the multisectoral response to HIV/AIDS
The Multi-Country AIDS Project
One of the key initiatives in the fight against HIV/AIDS is the Multi-country AIDS Project (MAP) funded by The World Bank. The highly decentralized MAP approach focuses on community- and district-level efforts. In Uganda, the MAP initiative is being carried out by the Uganda AIDS Control Project or UACP (hereafter referred to as the Project in this report).
In early 2004, the MAP initiative in Uganda will undergo a mid-term review, and in preparation for that review UACP, with the help of the World Bank’s Global AIDS Monitoring and Evaluation Support Team (GAMET), has carried out an assessment of the Project in 19 districts. The overall purpose of the assessment was to determine the impact of the Project’s efforts in certain key areas that are especially relevant to the three national HIV/AIDS goals listed above.
Specifically, the assessment was designed:
To assess the adequacy of care and support services for orphans To assess the adequacy of care and support services for PLWHAs To determine the knowledge and perception of men 15-54, women 15-49, and youth 15-24 on HIV/AIDS To determine the knowledge and perception of men 15-54, women 15-49, and youth 15-24 on STD prevention To determine the knowledge and perception of men 15-54, women 15-49, and youth 15-24 on the role of VCT as an HIV/AIDS prevention option To determine the knowledge and perception of men 15-54, women 15-49, and youth 15-24 on PMTCT To identify PMTCT practices among mothers of children 0-11 months To identify HIV/AIDS prevention practices among men, women, and youth To identify STD prevention practices among mothers of children 0-11 months
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To assess awareness and knowledge of men 15-54, women 15-49, and youth 15- 24 about HIV/AIDS-related services available in their community
For each of these 10 areas, a number of indicators were chosen to assess the current status. The indicators were derived from the goals of the National Strategic Framework described above, as well as from the monitoring and evaluation frameworks of other national HIV/AIDS programmes and UNGASS. In keeping with MAP’s decentralized approach, the assessment was carried out in the 19 districts using a method known as Lot Quality Assurance Sampling (LQAS), a data collection and analysis technique designed to be used by field staff at the local level to assess the impact of their activities. (The philosophy and methodology of LQAS are described in chapter 8.)
This report presents the major findings of the assessment, organized according to the six populations studied:
Chapter 1: Findings for Men 15-54 Chapter 2: Findings for Women 15-49 Chapter 3: Findings for Mothers of Children 0-11 Chapter 4: Findings for Young People 15-24 Chapter 5: Findings for Orphans 6-18 Chapter 6: Findings for People Living with HIV/AIDS Chapter 7: Findings of the Follow-Up Study Chapter 8: LQAS Philosophy and Methodology
District Variations
Readers are advised that the data presented in the tables in the main body of this report are averages for the 19 districts and do not necessarily tell the story for any one district. Indeed, in many cases the story in one district—how well or poorly that district is performing on any particular indicator—is very different from the story in other districts, and, therefore, very different from the data given in the tables.
For that reason, programme managers, local staff, and other interested readers should always consult the relevant table in the Appendices—which present survey results by individual district—before reaching any conclusions about their activities.
Readers are therefore advised that district specific result tables, which present survey results by individual counties, for all indicators assessed are available at the district HIV/AIDS coordination offices.
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Chapter 1: Findings for Men 15-54
Reducing HIV prevalence among men (as well as women) depends in part on what they know about the disease and prevention and on how they behave. For these reasons, the assessment sets out to establish how much men know about key variables that could influence their behaviour, as well as their knowledge of practices that increase the risk of exposure to HIV/AIDS. All results are weighted by the population size of the counties in which the sampling took place.
Voluntary Counseling and Testing
The NSF says that all programs in Uganda are supposed to publicize and promote the benefits of voluntary counseling and testing for HIV as a way of encouraging more men to get tested. The rationale behind this emphasis is that for men to undertake VCT they must clearly understand and be convinced of its benefits. The study, therefore, set out to determine how much knowledge there was among men about the benefits of VCT, using as an indicator the number of men who knew at least two of the benefits of VCT as promoted by the UACP programme. (These benefits are: to be able to plan one’s future, to avoid reinfection if one is already positive, and to learn to live positively with HIV/AIDS.)
As the results in Table 1.1 show, knowledge in this area is still low among men 15-54, with less than half being able to cite at least two benefits of VCT. It should be noted in this context that men of this age are most likely to be husbands of women in the reproductive age bracket, 15-49. Given the male-dominated decision-making structure in Ugandan culture, the fact that men have such low knowledge of the value of VCT has implications for the possibility of their wives going for testing and even of staying HIV negative.
Another reason to find out if men know the benefits of VCT is to help determine whether or not they will be likely to submit to an HIV test. As Table 1 shows, although nearly half of the men knew the benefits of VCT, only 14 per cent took the test. This would suggest that merely educating men about the benefits of VCT is not enough to make them take a test. Issues of access, availability and quality of information and services must be considered and addressed as necessary.
Table 1.1: VCT and MTCT Knowledge and Practice among Men LQAS Survey, Uganda, 2003.
Indicator % Reporting Confidence interval Men who know 2+ VCT benefits 46.8 2.08 Men who took an HIV test 14.3 1.5 Men who requested an HIV test 21.4 1.8 Men knowing the risk of mother- 79.6 1.7 to-child transmission
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Knowledge of Mother-to-Child Transmission of HIV/AIDS
Another strategy to contain the spread of HIV is to reduce the incidence of paediatric AIDS, whereby the virus is passed to a child from his/her HIV-positive mother. If women are going to try to prevent mother-to-child transmission of AIDS (MTCT), they need the support of their husbands, and husbands are more likely to offer support if they know about the risks of MTCT. Table 1.1 shows that four out of five men are aware of this risk.
Two other factors that may contribute to male support of preventing MTCT are for men to know: (1) the routes through which mother-to-child transmission takes place, and (2) that the risk of mother-to-child transmission can actually be reduced. Table 1.2 presents the three means of MTCT of HIV—during pregnancy, during delivery, and through breastfeeding— and male awareness of each. It is significant that while one third to two thirds of men know about at least one route of transmission, only six per cent knew of all three. The data presented here are for unprompted responses from men; men were asked whether or not HIV could be transmitted from mother to child, and if they said yes, they were asked to name the routes of transmission.
While 70 per cent of men mentioned that HIV can be passed to the infant during delivery, only 40 per cent mentioned the risk during pregnancy. This might suggest that men would not support their wives in seeking help during the antenatal period. The fact that only one third of men knew about the risks of MTCT during breastfeeding would suggest that they might assume breastfeeding was safe for children.
With regard to the second factor, Table 1.2 shows that many more men, 70 per cent, know that the risk of MTCT can be reduced. The challenge for programme staff will be to build on what men know, using it as an entry point for adding on what they do not know.
Table 1.2: Knowledge of MTCT Transmission Routes and Risk Reduction among Men, LQAS Survey, Uganda, 2003.
Indicator % Knowing Confidence interval Knowledge of transmission route/risk of reduction: Pregnancy 38.1 2.4 Delivery 70.3 2.2 Breastfeeding 33.2 2.2
Percentage knowing all 3 routes of 5.9 1.1 MTCT Knows that the MTCT risk can be 69.9 2.0 reduced
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Knowledge of the ABC’s of HIV/AIDS Prevention and Knowledge of Treatment for STI’s
Another strategy to prevent the spread of HIV/AIDS is the well-known ABC approach, where “A” stands for abstinence, “B” stands for be faithful to your partner, and “C” stands for the consistent and correct use of condoms during sex. Accordingly, the study measured male knowledge of at least two of the three ABC’s, and Table 1.3 below shows that just under two thirds of men knew two or more ABC’s.
A related strategy for AIDS prevention is the widespread treatment of sexually transmitted infections (STIs) in the general population. This strategy is based on the finding from several studies that the presence of an STI greatly increases the risk of HIV infection and transmission. Since effective treatment would depend in part on men being able to recognize the signs and symptoms of STIs, the study measured the number of men who know at least two signs or symptoms. Table 1.3 below shows that a little over half of the men surveyed could mention two or more signs/symptoms in men, suggesting that many men could go for a long period with an STI before seeking treatment, hence an elevated risk for HIV infection, and not be aware of it.
Since HIV/AIDS in Uganda is spread mainly through sexual relations, male knowledge of the signs and symptoms of STIs in women is another important factor in prevention, especially in light of the fact that men tend to dominate sexual decision-making. In this connection, the study sought to find out what percentage of men could recognize STI signs and symptoms in women. As Table 1.3 shows, just over 40 per cent of men had this knowledge, meaning that the female partners of almost 60 per cent of the men in the study area could have STIs and an elevated risk if HIV infection and their male partner would not know it.
Table 1.3: Men’s Knowledge of ABC and STI Symptoms, LQAS Survey, Uganda, 2003.
Confidence Knowledge Category % Knowing interval 2 + of Abstinence, Be 64.5 2.08 faithful, Condom use Mentions abstinence 44.8 2.16 Mentions being faithful 55.8 2.16 Mentions using condoms 73.5 1.96 2 + STI symptoms in men 51.6 2.14 2 + STI symptoms in 42.2 2.11 women Note: This table combines findings from Table A3 and A4 in Appendix A.
The UACP programme also has an initiative to reduce the incidence of STIs among men, particularly urethritis. The study therefore sought to determine how common this condition was among men in the study area, if they sought treatment, and if they paid for treatment. This latter point is important because treatment in government health facilities ought to be free of charge. Male respondents were asked whether in the 12 months preceding the survey they had had a burning sensation on urination (which is considered to be urethritis) or a discharge from the penis. The results presented in Table 1.4 reveal that about one in five men reported having had urethritis, which is a high level of prevalence when contrasted 2001 DHS
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result; 9 per cent of the sample reported having had a discharge from the penis in the 12 months preceding the survey.
In cases where people have STIs, the national programme strategy has been to ensure that they get treatment. The indicator here is the percentage of men who sought treatment for the discharge or burning sensation during urination, which, as can be seen in Table 1.4, was 62 per cent. Although this is more than a majority, it is still a point of concern that more than one third (nearly 40 per cent) of men did not seek treatment for these conditions and could be transmitting their infection.
It is also important to establish whether the men who seek treatment pay for it. As shown in Table 1.4, 72 per cent of men paid, a finding which suggests that either a good number of the men were receiving free services or that having to pay for services might have discouraged a number of men from accessing them, or some of both. While STI treatment in government ought to be free, 52 of 124 (42 per cent) men who sought treatment had to pay for the service.
Table 1.4: Prevalence of Urethritis and Urethral Discharge among Men and Their Treatment Patterns, LQAS Survey, Uganda, 2003.
% Confidence Condition Reporting interval Urethritis 18.8 1.78 Urethral discharge 1.39 8.9 Sought treatment for condition 61.8 4.37
Paid for treatment 72.2 5.6
Table 1. 4A: Cross Tabulation of the Location Where Men Who Sought Treatment Were Treated for Discharge from Their Penis or Burning during Urination by Whether They Paid for the Treatment, LQAS Survey, Uganda, 2003.
Location where Paid for treatment of discharge or burning treated for during urination discharge or burning during YES NO Total urination Government 52 72 124 health facility Private health 109 7 116 facility Traditional healer 7 2 9 Pharmacy 15 1 16 Self-medication 16 3 19 Other 5 1 6 Total 204 86 290
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Another important indicator of STI treatment is whether men seek treatment in places that can provide complete and reliable services. As Table 1.5 shows, 79 per cent of men in this study sought treatment from dependable sources, i.e., government and private health facilities. 3.8 per cent used traditional healers, 9.7 per cent engaged in self-medication, and 9.7 per cent sought treatment from a pharmacy.
Table 1.5. Facility Type for Those Who Sought Treatment, LQAS Survey, Uganda, 2003.
Type of Facility Government Private Traditional Pharmacy Self- Other health health healer medica- facility facility tion
Men seeking 41.7 37.2 3.8 6.2 9.7 1.4 treatment
Misconceptions about HIV/AIDS
In addition to the strategies mentioned above, the UAC also has a campaign to dispel misconceptions about how HIV is spread. This is an important component of a general campaign to educate the population and keep them from engaging in practices that would give them a false sense of protection. Respondents were asked whether HIV could be transmitted in the following ways, all of which are misconceptions: through mosquito bites, touching an infected person, sharing utensils with an infected person, and sharing toilets with an infected person.
According to the data presented in Table 1.6, the most widely held misconception concerns mosquitoes, with 38 per cent of the men interviewed believing HIV could be transmitted in this way, followed by toilet seats (believed by 18 per cent). Just over half of all men, meanwhile, rejected all five of the most common misconceptions. These findings suggest that nearly half of those surveyed are likely to engage in some form of false fear, such as avoiding mosquito bites or not sharing utensils with people who are HIV positive – the latter of which can accentuate stigma.
Table 1.6: Percentage of Men who Reject Common Misconceptions on HIV Transmission, LQAS Survey, Uganda, 2003.
Misconception % Confidence Rejecting interval Through mosquitoes 62.2 9.8 Touching infected person 89.1 6.4 Sharing utensils 82.9 6.9 Sharing toilets 82.1 7.5 Through witchcraft 87.5 5.9
Rejecting all five 51.1 2.14
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Self-Assessment of Risk
One factor that makes a particular behaviour more or less likely is the perceived degree of risk. The study undertook to measure men’s assessment of whether or not they believed they were at risk for getting HIV/AIDS, the reasons for their perceived degree of risk, and the validity of those reasons. Table 1.7 shows that a third of the men considered themselves to be at high risk of HIV infection.
Table 1.7 also seems to suggest that a common assumption about HIV/AIDS—that people who are better educated have a better understanding of the risks—may not be accurate. Except for those with a post-secondary education, the table shows that there is virtually no variation across educational groups among those men who considered themselves at high risk. Table 1.7: HIV Risk Assessment among Men by Level of Education, LQAS Survey, Uganda, 2003.
Risk % Reporting Confidence assessment/education interval Perceive themselves at 32.5 2.0 high risk
High risk by educational groups: None 33.4 7.3 Primary 34.5 2.6 Secondary 34.7 4.1 Post-secondary 22.7 6.5
The findings in Table 1.8, regarding the reasons why men believe themselves to be at high or low risk, show that men generally do not have an accurate assessment of high risk, with the exception of the low number (4.5 per cent) who consider themselves at high risk because they are unmarried.
The most striking finding here by far is that only 16.3 per cent of men consider not using condoms as a high risk factor—when not using a condom is in fact the single highest risk factor in the sexual transmission of AIDS.
In the low or no risk category it is noteworthy that the most commonly cited reason here is that partners are faithful to each other. But in point of fact a married man (or woman) can only know if he/she is faithful; not being able to guarantee one’s partner’s faithfulness means that fidelity cannot on its own be considered a protection against risk.
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Table 1.8: Men’s Perceived Risk Assessment and their Reasons, LQAS Survey, Uganda, 2003.
Respondents of this class of % Confidence perceived risk who mentioned Reporting interval this reason High risk: 32.5 2.0 Not married 4.5 1.0 No steady partner 19.7 1.4 Do not use condoms 16.3 1.4 Don’t trust partner 39.3 2.0 Many partners 32.48 1.6 Most people infected 11.8 1.1
Low or no risk: 59.0 2.1 Not married 4.16 1.0 Abstaining 4.18 0.8 Married 41.27 2.0 Faithful 97.3 1.3 Use condoms 10.68 1.1 Still a virgin 0.88 0.4 Still young 1.24 0.6
Condom Use
With regard to risk, the Project strongly promotes condom use among all population groups, and the study asked men whether or not they had ever used a condom. As Table 1.9 shows, more than half of men had used a condom at least once.
The study also set out to establish the prevalence of sexual relations with non-regular partners, another risk factor targeted by the national effort. Men were asked whether in the 12 months preceding the survey they had had sex with someone other than their wife or regular partner, and nearly one quarter reported that they had.
As Table 1.9 shows, only 42 per cent of those who had sex with a non-regular partner reported using a condom during the last sexual contact with a non-regular partner, suggesting that casual sex in the study population is a big risk factor.
Table 1.9: Sexual Behaviour and Condom Use among Men, LQAS Survey, Uganda, 2003.
% Confidence Behaviour Reporting interval Ever used a condom 50.9 2.14 Had sex with non-regular 23.7 1.88 partner in 12 month period Used condom with non- 42 4.46 regular partner
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Chapter 2: Findings for Women 15-49
The assessment of the Ugandan HIV/AIDS programme asked similar questions of and measured many of the same indicators for women as for men. As with men the overall goal was to understand how much women know about and what their behaviours are vis a vis HIV/AIDS so that UACP staff can decide where to target their resources, how well their efforts are succeeding, and where changes may need to be made.
Voluntary Counseling and Testing
As with men, a very important starting point for preventing the spread of HIV/AIDS is for women of reproductive age (15-49) to know their sero-status. Women should therefore be encouraged to get voluntary counseling and testing (VCT) for HIV. Since women are more likely to go for VCT if they understand and are convinced of its benefits, the study set out to establish the level of knowledge among women about the benefits. The indicator of this knowledge was the number of women who knew at least two of the benefits of VCT as promoted by the national campaign.
As demonstrated in Table 2.1, knowledge in this area among women is still relatively low, just over one third. It is important to note here that these are women in the reproductive age group and thus at the highest risk of sexually transmitted HIV infection.
One important reason to find out whether women know the benefits of VCT is the likelihood that if they know the benefits, then they will be more inclined to get tested for HIV. Table 2.1 shows that while almost 40 per cent of women know the benefits of VCT, only 14 per cent had taken the test. Clearly, awareness of the benefits by itself is not a sufficient condition to motivate women to be tested.
Table 2.1: VCT and MTCT Knowledge and Practice among Women, LQAS Survey, Uganda, 2003.
% Confidence Indicator Reporting interval Women who know 2+ 38.8 2.1 VCT benefits Women who requested 21.9 1.73 an HIV test Women who took an 13.8 1.4 HIV test Women knowing about risk of mother-to-child 78.1 1.8 transmission
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Knowledge of Mother-to-Child Transmission of HIV/AIDS
Another strategy to contain the spread of HIV is to reduce the incidence of paediatric AIDS or mother-to-child transmission (MTCT). It can be assumed that only women who know about the risk of MTCT are likely to participate in this strategy. As Table 2.1 demonstrates, knowledge of MTCT among women is 78 per cent.
Merely knowing the risk of MTCT, however, is usually not by itself sufficient motivation for women to participate in this initiative. There are two other important conditions that may need to be met: (1) women must know the routes through which mother-to-child transmission takes place; and (2) women must know that the risk of mother-to-child transmission can actually be reduced. Table 2.2 shows that fewer than 10 per cent of the women surveyed knew all three routes of MTCT—during pregnancy, during delivery, and post-partum through breastfeeding—suggesting that at a minimum more education is needed before women will take preventive action against all three risks.
With reference to the other condition, knowing that the risk can be reduced, Table 2.2 shows that just over half of women knew about this possibility. The other half, presumably, will not be motivated to take steps to reduce MTCT since they are not aware that it’s possible. Once again, more education will be necessary.
Table 2.2: Knowledge of MTCT Transmission Routes and Risk Reduction among Women, LQAS Survey, Uganda, 2003.
Transmission Route/Risk Reduction % Confidence Knowing interval Pregnancy (unprompted) 38.1 2.5 Delivery (unprompted) 69.1 2.3 Breastfeeding (unprompted) 36.8 2.0
Knowing all 3 routes of MTCT 9.3 1.2
Know that the MTCT risk can be reduced 51.7 2.2 Know that the MTCT risk can be reduced and also the 3 routes of transmission 7.3 1.1
Knowledge of the ABC’S of HIV/AIDS Prevention and Knowledge of Treatment for STIs
Another focus of the Project in Uganda is to prevent the spread of HIV through sexual transmission in the general population. This effort makes use of the ABC strategy, where “A” stands for abstinence from sex, “B” stand for being faithful to one’s sexual partner, and “C” stands for the consistent and correct use of condoms. The study sought to find out to what extent women had internalised the ABC messages, using as its indicator the per cent of women who know at least two of the three preventive measures promoted by the Project. Table 2.3 shows that less than half of women knew two or more of the three ABC practices.
Another programme strategy is the widespread treatment of sexually transmitted infections (STIs) in the general population. This strategy is based on the finding from several studies
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that the presence of an STI greatly increases one’s risk of HIV infection. For women to seek treatment, they must first be able to recognize the symptoms of STIs, and accordingly the study set out to measure knowledge among women of the signs and symptoms of STIs. The indicator used here was the percentage of women who know at least two signs or symptoms. Table 2.3 shows that just over half of women could cite two or more STI signs and symptoms in themselves, meaning that nearly half of women could go for months with an STI, hence an elevated risk of HIV infection, without being aware of it or seeking treatment.
Since HIV/AIDS in Uganda is spread mainly through sexual relations, women’s knowledge of the signs and symptoms of STIs in men is another important factor in prevention. Women who had that kind of knowledge could help fight the spread of HIV either by refusing to have sex with a man who has those signs or by advising him to go for treatment, or both. In this regard, the results presented in Table 2.3 are disappointing, with only a third of women able to recognize the signs and symptoms of STIs in men. This means that the male partners of two thirds of the women in this study area could have STIs and an elevated risk of HIV infection or transmission and their female partner would not realize this. If these women then went ahead and had sex with these men, they could not only infect themselves with an STI, but they would also be putting themselves at an increased risk of getting HIV.
Table 2.3: Women’s Knowledge of ABC and STI Symptoms, LQAS Survey, Uganda, 2003.
Knowledge Category % Confidence Knowing interval 2 + of Abstinence, Be faithful, Condom use 49.7 2.15 Mentions abstinence 43.9 2.15 Mentions being faithful 45.4 2.14 Mentions using condoms 61.9 1.99 2 + STI symptoms in women 52.9 2.14
2 + STI symptoms in men 32.9 1.99
Misconceptions about HIV/AIDS
The Ugandan programme includes a campaign to dispel misconceptions about how the AIDS virus is spread. This is an important component of a campaign to educate the general population and keep them from engaging in practices that would give them a false sense of security or increase stigma of those who are HIV infected. A key Project indicator in this regard is the number of women who reject all of the five major misconceptions about HIV transmission. As Table 2.4 shows, just over 40 per cent of women rejected all five, leaving 60 per cent likely to engage in some form of false protection or fear, such as avoiding mosquito bites or not sharing toilets with people who are HIV positive.
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Table 2.4. Percentage of Women Who Reject Common Misconceptions about HIV Transmission, LQAS Survey, Uganda, 2003.
Misconception % Confidence Rejecting interval Through mosquitoes 53.8 2.94 Touching infected person 85.5 1.71 Sharing utensils 80.3 2.01 Sharing toilets 74.8 2.19 Through witchcraft 82.5 1.90
Rejecting all five 41.2 2.10
Self-Assessment of Risk
In light of persistent misconceptions about how HIV is transmitted and the percentage of women who did not know signs of STIs or even two of the ABCs, the study undertook to measure whether or not women believed they were at risk for getting HIV/AIDS. Table 2.5 shows that 36 per cent of women considered themselves to be at high risk of HIV infection. Although this is a very high percentage by most standards, it is noteworthy—and a cause for concern—that this figure is 14 per cent lower than the 50 per cent of women who reported not knowing even two of the ABCs and who are, therefore, at considerable risk of getting HIV.
It is interesting that the main reason women perceive themselves to be at high risk is that they do not trust their partners (nearly 60 per cent). However, 37.5 per cent say they either have no steady partner or several partners. Not being married is not associated with this risk level. Conversely, women who perceive themselves to be at low or no risk report as their reason that they are faithful to their partner or married.
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Table 2.5. HIV Risk Assessment among Women, LQAS Survey, Uganda, 2003.
Reason reported for having % Confidence this perceived level of risk Reporting interval Perceived High Risk 35.9 2.05 Not married 3.8 0.94 No steady partner 21.6 1.56 Do not use condoms 11.3 1.17 Don’t trust partner 59.8 2.31 Have many partners 15.9 1.25 Most people are infected 8.2 1.02
Perceived Low or No Risk 51.7 4.57 Not married 3.94 0.94 Abstaining 9.61 1.03 Married 22.87 1.75 Faithful to each other 32.37 1.83 Using condoms 4.07 0.73 Still a virgin 0.86 0.45 Still young 0.23 0.33
Table 2.6: HIV Risk Assessment among Women by Level of Education, LQAS Survey, Uganda, 2003.
Percentage of women perceiving Highest level of themselves at various levels of schooling risk completed Don’t High Low No Total Know None 18.33 15.88 28.93 31.43 21.54 Primary 57.37 59.84 55.32 52.14 57.01 Secondary 21.13 20.87 13.08 13.42 18.34 Post-secondary 3.18 3.41 2.67 3.00 3.11 Total 100 100 100 100 100
Condom Use
Condom use is yet another protection strategy promoted by the Project. The study therefore took particular interest in finding out what per cent of women had ever used a condom. The results, presented in Table 2.7, show that only about 30 per cent of women reported ever using a condom, a disturbingly low figure in light of the level of risk outlined above.
On a related indicator, however, which is also another high risk factor for HIV, women were doing better (and doing much better than men). As Table 2.7 shows, only 9 per cent of women reported having sex with non-regular partners in the 12 months preceding the survey (as compared with just under 24 per cent of men). Asked whether they had used a condom during their last sexual contact with a non-regular partner, just over one third answered yes.
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Clearly, casual sex is a very low risk factor in this study population, although those that engage in it are at very high risk because only 37.1 per cent use condoms.
Table 2.7: Sexual Behaviour and Condom Use among Women, LQAS Survey, Uganda, 2003.
Behaviour % Confidence Reporting interval Ever used a condom 31.4 1.91 Had sex with non-regular 8.7 1.20 partner in 12 month period Used condom in last contact 37.1 7.47 with non-regular partner
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Chapter 3: Findings for Mothers of Children 0-11
With regard to pregnant women, the main thrust of the UACP initiative has been preventing mother-to-child transmission of HIV/AIDS (MTCT). To get information about the knowledge, attitudes, and practices of pregnant women, the study interviewed mothers with children between 0 and 11 months of age at the time of the survey. This population was selected because of their relatively recent contact with the health system, making their observations more current.
Knowledge of Mother-to-Child Transmission of HIV/AIDS
If preventing MTCT is to be considered a viable goal, would-be mothers should be aware of the risk of mother-to-child transmission and the possibility of reducing that risk. Thus the study began by establishing whether mothers in the target group knew about the risk of MTCT, and, as Table 3.1 shows, more than 80 per cent of mothers did. Despite this high level of knowledge, however, only about half of those surveyed knew that this risk of MTCT could be reduced.
Table 3.1: Mothers’ Knowledge about the Risk of Mother-to-Child Transmission of HIV, LQAS Survey, Uganda, 2003.
% Confidence Indicator Reporting interval Knows about mother-to-child transmission 80.8 1.76 Knows risk of MTCT can be 51.6 2.14 reduced
Use of Antenatal Care Services
Another key variable in preventing MTCT is the use of antenatal care (ANC) services, as this is where most mothers first learn about MTCT and are recruited into the prevention programme. Mothers were asked, therefore, whether they had attended ANC for their index pregnancy. Table 3.2 shows that the overwhelming majority (92 per cent) of mothers had attended ANC, which suggests that most women had at least the potential to be exposed to MTCT education and counseling.
For MTCT prevention to actually work, mothers should adhere to certain procedures set up by ANC facilities. These include making the required minimal number of antenatal care visits (a total of four) as well as proper filling out by health facility staff of the maternal cards on which details about the visits are recorded. But when mothers were asked for their maternal cards (Table 3.2), only a quarter could present them, another quarter reported that they had lost their cards, and more than thirty per cent reported the card was “in another location.”
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As for whether they made the recommended number of visits, this question was put only to those mothers who presented their cards (to avoid the recall bias often encountered in questions of this nature), and the interviewers copied the number of visits noted on each woman’s card directly into the questionnaire. Table 3.2 shows that of the few mothers who had cards, slightly more than one third (35.9 per cent) had made four or more antenatal visits, and another 20 per cent had made three visits. Three visits was the number recommended by the Ministry of Health before the advent of PMTCT. If this result is generalized to the population of all mothers with infants, it suggests that these women may be open to making a fourth visit if it was suggested to them. However, this result may be somewhat biased since women who have maternal cards may be more faithful users of ANC services.
Table 3.2: Mothers’ Use of Antenatal Care Services, LQAS Survey, Uganda, 2003.
Indicator % Confidence Reporting interval Attended ANC 92.0 1.24 Mother asked for maternal card: Showed card 25.9 Lost card 25.9 Never had card 5.4 7.76 Card in another location 31.3 Other 3.3 Never went to ANC 8.2 Number of antenatal care visits recorded on card: 1 17.6 2 24.7 11.70 3 20.9 4 25.5 5 + 10.4
Delivery in a Health Facility
A second key element of the PMTCT intervention is that pregnant women deliver in a health facility, and the study measured this indicator by asking mothers where they had delivered their last child. The results presented in Table 3.3 show that half of mothers had their most recent delivery in a health facility, and the other half delivered at home. In order for HIV infected mothers and newborns to receive antiretroviral treatment (ART) they need to deliver at a health facility.
Even mothers who deliver at home, however, can better avoid the risk of MTCT if there is a clinically trained provider present who can provide ART. Accordingly, the study asked mothers who attended ANC if they delivered under the care of a trained provider (a doctor, midwife, or nurse). As shown in Table 3.3, just over half of mothers did so, another 20 per cent delivered under the care of family members, 16 per cent were assisted by TBAs, and 8 per cent delivered on their own without any assistance. These findings indicate that of the half of women who deliver at home, 50 per cent may be exposing their infants and those assisting the birth to the risk of HIV.
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Table 3.3. Women’s Delivery Practices, LQAS Survey, Uganda, 2003.
Delivery Practice % Confidence Reporting interval Place of birth: Delivered in health facility 51.2 2.1 Delivered at home or other place 48.8 6.5
Assistance at delivery: Delivered under trained provider 52.8 2.1 Delivered under other person 47.2 5.6
Counseling on MTCT and VCT
ANC visits can only meet their potential to prevent MTCT if women are counseled on the topic during such visits. Table 3.4 shows that this opportunity to fight HIV/AIDS is being missed more often than not, with only 44 per cent of those surveyed reporting MTCT counseling.
The results are not significantly better when it comes to another key element in preventing MTCT: getting tested for HIV (which is a prerequisite for being treated with an ART during delivery). The study asked two questions about this topic: whether mothers were counseled about testing and whether they actually took a test. The results, presented in Table 3.4, are disappointing; only 39 per cent of women who went for ANC were counseled about testing, and of those who were counseled only about one third took the test. In total only 13 per cent of mothers actually got tested. These findings suggest that it is not enough to solve the “supply” side of the prevention problem (i.e., by making services available) but that the “demand” side must be developed as well.
Table 3.4. Counseling and Testing Patterns among Pregnant Women, LQAS Survey, Uganda, 2003.
Counseling/Testing % Confidence Reporting interval Counseled about PMTCT 43.8 2.39 Counseled to take HIV test 37.9 2.18 Took HIV test 12.8 1.47 Took a Test and Counseled 34.9 1.47 to Take a Test
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Chapter 4: Findings for Young People 15-24
With regard to young people ages 15-24, the programs promote sexual abstinence until marriage. Since sexual intercourse is by far the most common mode of HIV transmission, sexual abstinence would provide almost complete protection for most young people. The UACP, although it has had no specific strategy, encourages young people to take an HIV test before marriage; and after marriage to stay faithful to one partner. For those who cannot adhere to these guidelines, the Project urges condom use. The study set out to determine how much young people know about the risk of HIV infection and to identify the frequency of certain sexual behaviours that might expose them to risk. It should be noted that there is always a risk of reporting bias whenever anyone is asked an intimate question such as about sexual behaviour.
Knowledge of the ABC’s of AIDS Prevention
As a starting point, the study measured how much young people know about ways to prevent the sexual transmission of HIV, using as an indicator the percentage of young people who could cite at least two of the ABC’s of prevention. Table 4.1shows that just over half of young people know two or more ABC’s of prevention: abstinence, faithfulness to one partner, and condom use.
The study also wanted to determine if knowledge was associated with age, whether older youths are more knowledgeable than younger ones. Table 4.1 suggests an association between knowledge and age; while only forty per cent of youths aged 15-17 knew at least two ways to prevent HIV transmission, nearly 60 per cent among youths aged 18-24 had this knowledge (and logistic regression revealed that this association was statistically significant).
A much stronger association was noted between the level of education of youth and their knowledge of two or more ABC’s. Secondary and post secondary school attenders were much more likely to know two or more ABC’s.
The study also measured how much young people know about each of the three prevention strategies. This is particularly important considering that the programme’s focus with young people is on reducing casual sexual activity. However, it does support UNAIDS recommendations of promoting abstinence until marriage. Table 4.1 shows that only half of young people reported knowing abstinence as a way to prevent transmission. Equally worrying is that although the majority of young people reported that they were sexually active, only 28 per cent knew faithfulness as a prevention strategy. On the positive side, three quarters of young people knew of condom use as a means of protection.
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Table 4.1: Young People’s knowledge of ABC by Age and Schooling, LQAS Survey, Uganda, 2003.
Characteristic % Confidence Knowing interval Knows 2+ of Abstinence, Be faithful, Condom use 52.4 2.2 15-17 39.9 3.8 18-24 57.7 2.6 Highest level of school
attended: Never Attended 39.4% Primary 43.6% Secondary 64.7% Post secondary 76.3% Knowledge of individual
strategies: Abstinence 52.2 2.2 Be faithful 28.2 2.0 Condom Use 74.8 1.9
Sexual Behaviour
Table 4.2 shows the percentage of young people by age who have started having sex. UNAIDS recommends calculating the median age at first sex by identifying the first age group in which at least 50 per cent of youths have had their sexual initiation. It is clear from this table that sexual activity starts at a young age in the study population; a quarter of the fifteen-year-olds reported having had sex already, a third of sixteen-year-olds had already had sex, and more than half of all youths had already experienced sex by age 17 (the median age for this survey).
Given the lower levels of knowledge of protection among younger youths, the information in Table 4.2 may suggest that sexually active younger youths are at a high risk of infection and should be targeted with prevention activities.
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Table 4.2: Percentage of Young People Who Had Sex at the Different Ages, LQAS Survey, Uganda, 2003.
Age % Who have Confidence had sex interval 15 24.3 5.8 16 32.0 6.1 17 53.9 6.5 18 55.6 6.0 19 65.3 6.1 20 82.2 4.7 21 80.3 5.6 22 91.3 4.4 23 88.0 4.5 24 94.4 3.6 Virgins 33.6 4.2
In addition to an early sexual initiation, another risk factor is having sex with non-regular partners. The study asked young people whether they had had sex with a non-regular partner in the 12 months preceding the survey, and Table 4.3 shows that nearly a third of the young people answered in the affirmative. In the absence of any kind of protection, this is a very high risk factor for HIV infection. Accordingly, young people were also asked whether they had used a condom during their first sexual encounter. Table 4.3 shows that just over one third of young people had, suggesting that the remaining two thirds have run the risk of being infected with HIV at their very first sexual experience.
To further explore the issue of protection, young people were asked whether they used a condom when they last had sex with a non-regular partner, and more than half said they did (Table 4.3). It is likely but not certain that these same people are more inclined than not to similarly protect themselves at subsequent sexual encounters. For the moment the pressing need is to identify why more young people don’t use a condom during their first sexual experience.
Although more than half of the young people reported using a condom in their last sexual contact with a non-regular partner, another important indicator of protection is young people who consistently use condoms whenever they have sex. The results in Table 4.3 show that only a quarter of young people fall into this category, meaning that the remaining three quarters of young people expose themselves to the risk of infection at one time or another in the course of their sex life.
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Table 4.3. Sex Practices and Condom Use among Sexually Active Young People, LQAS Survey, Uganda, 2003.
Practice % Confidence Reporting interval Had sex with non-regular partner in 12 months before 30.2 2.5 survey Used a condom at first sex 35.7 2.6 Used a condom in last sex with non-regular partner 55.7 5.2 Always uses a condom in sex 25.5 2.2
Correct Use of Condoms
If condoms are not used correctly, they do not provide protection. Accordingly, the study set out to determine how many young people knew how to use a condom correctly by asking them to spontaneously describe the steps a person goes through to use a condom. It was assumed that a respondent knew the correct use of a condom if he or she could describe at least three of the six steps. As Table 4.4 demonstrates, only 30 per cent of young people could be said to know how to use a condom correctly.
Of the six steps, the one cited most often is “tearing the packet” (37 per cent). Some of the more crucial ones, such as “check date of expiry” (17 per cent) and “remove before penis is flabby” (20 per cent), got less mention.
Table 4.4. Young People’s Knowledge of Correct Condom Use, LQAS Survey, Uganda, 2003.
% Confidence Action Reporting interval Check date 17.0 1.6 Tear packet 36.6 2.1 Hold tip while unrolling 28.9 2.0 Put on erect penis 34.9 2.1 If condom unrolled upside down and touches penis, 13.4 1.4 use new condom Remove before penis is 19.6 1.7 flabby
Correct condom use: 3+ of 30.0 2.0 the above steps mentioned
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Self-Assessment of Risk and Misconceptions about Transmission
The study was also interested in finding out at what level of risk to HIV infection young people see themselves. Young people were asked whether they assessed their risk as high or low. Table 4.5 shows that while a third of young people considered themselves to be at high risk, 57 per cent considered themselves at low or no risk. These results are similar to the adult population in that the most common reason mentioned among those perceiving themselves to be at high risk is that they do not trust their partners. Those perceiving themselves as being at low or no risk most commonly mention they are abstaining. However, the latter group also mentions that not being married is a protective factor, suggesting that lack of trust in one’s partner is (correctly) seen by youth as a risk factor.
Table 4.5: Risk Perception and Rejection of Common Misconceptions on HIV Transmission among Young People, LQAS Survey, Uganda, 2003.
Confidence % interval Perceived high risk 32.6 4.4 Respondents of this class of perceived risk who mentioned this reason I am not married 26.4 2.9 I have no steady partner 24.7 1.5 I do not use condoms 15.75 1.23 Don’t trust my partner 35.6 1.76 I have many partners 16.53 1.15 Most people are infected 9.57 1.13
Perceived low or no risk 57.0 4.4 Respondents of this class of perceived risk who mentioned this reason I am not married 18.5 2.9 Abstaining 24.5 1.7 Married 6.7 1.03 We are faithful to each other 12.9 1.31 I use condoms 12.51 1.23 I am still a virgin 16.66 1.36 I am still young 16.95 1.51
The more misconceptions people have about how HIV is transmitted, the more likely they are to: (1) be at risk from the true causes of transmission, and (2) have a false sense of security in having protected themselves from nonexistent risks. In the survey young people were asked about five major misconceptions about HIV transmission, namely that it can be spread by mosquito bites, touching an infected person, sharing utensils with an infected person, sharing a toilet with an infected person, and through witchcraft. Their responses, presented in Table 4.6, show that only 45 per cent of young people reject all of these misconceptions. In other words, more than half believe one or more untruths about how HIV spreads. This table further reveals that the most prominent misconception is the one about mosquito bites, with
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more than 40 per cent of youths believing that HIV can be transmitted in this manner. All of the four remaining misconceptions were rejected by at least 77 per cent of youth.
Table 4.6: Rejection of Common Misconceptions on HIV Transmission among Young People, LQAS Survey, Uganda, 2003.
Misconception: % Confidence Rejecting interval Mosquitoes 57.8 8.9 Touching and infected 88.9 6.1 person Sharing Utensils 77.7 6.9 Sharing Toilets 79.8 7.6 Witchcraft 86.9 7.1
Rejecting all five 44.8 2.1 misconceptions
Knowledge of Sexually Transmitted Infections and of MTCT
Another risk factor connected with HIV is sexually transmitted infections. Since it has been established that having an STI considerably increases one’s risk of HIV infection, the Project in Uganda promotes education about and early complete treatment of STIs whenever they occur. For this approach to be successful, obviously, young people must be able to recognize the signs and symptoms of STIs.
Young respondents were asked if they could spontaneously name the signs and symptoms of STIs, using as the indicator whether a person could name at least two signs or symptoms. Table 4.7 shows that only a quarter of young people could recognize the signs and symptoms of STIs in men and only a third could recognize them in women. This low level of knowledge underscores again the high level of risk that these young people may face.
Early identification of pregnant women with HIV infection and the appropriate use of ART can increase the possibility of preventing mother-to-child transmission (PMTCT) of the AIDS virus. Among other things, preventing MTCT requires that people are aware of the possibility of transmitting AIDS in this way in the first place. This awareness is particularly important for young people because they are the next generation of parents. Table 4.7 shows that there is a very high level of awareness of mother-to-child transmission, with over 80 per cent of young people knowing the existence of this risk.
For the PMTCT initiative to be effective, young people must also know that there is a possibility of reducing the risk of mother-to-child transmission. The results in Table 4.7 show that although four out of five young people knew about the risk of a mother passing on her infection to her unborn baby, just over half knew about the possibility of reducing that risk.
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Table 4.7. Knowledge of STI Symptoms and MTCT Risk among Young People, LQAS Survey, Uganda, 2003.
Knowledge category % Confidence Reporting interval 2+ STI symptoms in men 31.4 1.9 2+ STI symptoms in women 32.2 2.0 Knows of MTCT of HIV 81.1 1.76 infection Knows MTCT risk can be reduced 56.1 2.2
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Chapter 5: Findings for Orphans 6-18
In the National Strategic Framework, the policy towards orphans is set out in the children’s statute. The goal is to protect the right of orphans to:
Shelter Education Health care Safety General well-being.
The goal of the assessment was to measure the adequacy of care and support services for orphans. Specifically, the study set out to establish whether or not orphans were receiving assistance for education, health care and psychosocial support. The three areas are priorities of the NSF.
Types of Orphans
To begin with the study determined what kind of orphans were prevalent in the study area; were they paternal orphans (who had lost only their father), maternal orphans (without a mother), or complete orphans (with neither mother nor father). This information is useful as different kinds of orphans have different needs, with obvious programme implications. The data presented in Table 5.1 show that paternal orphans are by far the most common, accounting for nearly half of all orphans in the study communities. Complete orphans were also relatively common—36 per cent of those surveyed—while less than 20 per cent were maternal orphans.
It was also important to establish the gender of the orphans since male and female orphans need different kinds of care and support. As Table 5.1 shows, there are more males than females in the orphan sample, 55 per cent and 45 per cent respectively. The ages are evenly distributed with some minor variation. However, after 15 years of age the population begins to attenuate.
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Table 5.1: Selected Socio-demographic Characteristics of Orphans, LQAS Survey, Uganda, 2003.
Characteristic %
Orphan type: Maternal 17.0 Paternal 47.3 Complete 35.8
Sex of orphan: Male 54.7
Female 45.3
Age of orphan 6 7.87 7 7.15 8 6.76 9 6.62 10 8.94 11 5.75 12 10.58 13 9.81 14 9.28 15 10.10 16 6.33 17 5.75 18 5.07 Total 100
Education
A key need of orphans is education, so the study looked at whether or not orphans are in school. Table 5.2 shows that the overwhelming majority of orphans (82 per cent) were in school, although the 6-7 years olds are about 15 percentage points below the older children. This pattern ends at 14 years of age when the proportion of orphans attending school diminishes sharply.
Of those who did attend school (Table 5.3), three quarters of them attended school five days in the week preceding the survey, suggesting strongly that they are not attending in name only.
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Table 5.2: School Attendance among Orphans by Age, LQAS Survey, Uganda, 2003.
ORPHANS IN SCHOOL 82.33 Age distribution 6 81.08 7 77.67 8 95.15 9 90.41 10 93.84 11 95.14 12 92.57 13 92.31 14 82.92 15 81.39 16 72.61 17 51.96 18 30.93
Only four per cent of the orphans were reported never to have attended school at all, and the rest had attended at least through the primary level. Even so, the majority of the orphans (87 per cent) listed the primary level as their highest level of schooling attended. This finding is associated with the age distribution of 6-18 years; most participants are not old enough to have completed secondary school. However, given the finding that larger proportions of older orphans are no longer in school, there may be barriers to accessing secondary and higher education that need to be understood.
Table 5.3: School Attendance among Orphans Who Attend School by Days Attended and Level of Schooling, LQAS Survey, Uganda, 2003.
Number of days % attended in week preceding survey: 0 6.77 1 2.09 2 2.62 3 7.28 4 7.83 5 73.41 Highest level attended: Never 3.8 Primary 87.1 Secondary 9.0 Post-secondary 0.2
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Care and Support
Since care and support to orphans is one of the key areas being addressed by the Project, the study wanted to find out what percentage of orphans were getting the various kinds of support that were available. In general, the study found that there were very few orphans who were getting any kind of support.
Table 5.4 shows that only 15 per cent of the orphans were getting educational support, typically in the form of assistance with school fees, uniforms, and scholastic materials.
It has generally been established that orphans also need psychological and social support to help them handle the situation they find themselves in. A key project indicator, therefore, measures the percentage of orphans who are receiving psychosocial support (such as counseling) in project communities by asking whether orphans had received any kind of psychosocial support in the one month preceding the survey. Table 5.4 shows that only a tenth of those surveyed had received this kind of counseling.
A third need among orphans is for material support. Orphans or their guardians were asked whether they had received this kind of support in the year preceding the survey, especially, beddings, clothing, and agricultural materials. As Table 5.4 exhibits, only five per cent of the orphans were receiving any kind of material support. Only two per cent had received beddings, and just under three per cent had received either clothing support or agricultural materials.
An equally disturbing finding from Table 5.4 is the fact that a mere three per cent of orphans had received food support within a month of the survey.
At this stage, orphan care and support is minimal in the study areas and needs to be improved.
Table 5.4: Patterns of Orphan Support, LQAS Survey, Uganda, 2003.
% Confidence Types of support Reporting interval Educational support: 15.4 1.60 School fees 12.9 1.62 Uniforms 10.8 1.60 Scholastic materials 13.2 1.70 Psychosocial support 9.7 1.30 Professional counseling 4.3 0.84 Taken to counseling centre 2.8 0.76 Community support group 6.1 1.10 Material support 5.3 0.98 Beddings 2.0 0.68 Clothing 2.9 0.75 Agricultural materials 2.6 0.71 Food support 3.5 0.78
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Chapter 6: Findings for People Living with HIV/AIDS
The UACP has tried to promote various practices among people living with HIV/AIDS (PLWHAs) which would make their lives more bearable. In particular, the Project aims to:
improve the ability of communities, households, and individuals to prevent or cope with the impact of HIV/AIDS, through community-led HIV/AIDS initiatives; and
extend the productive life of people living with AIDS.
The assessment reported here does not necessarily include all organizations receiving UACP support. Rather it is intend to provide lessons that the UACP can learn from and which it can use for programme development.
A Profile of PLWHAs
The study set out to assess the adequacy of care and support services for PLWHAs and determine whether the Project objectives were being met. The first step, to establish a profile of PLWHAs, asked respondents about their ages, their educational level, and marital status. Table 6.1 shows that there was a negligible number of minors (people below reproductive age) in this population group (one per cent) and that less than five per cent of PLWHAs in the study were young people. The majority (51 per cent) were ages 35-49; younger adults ages 25-34 constituted a third; and people over 50 were about one tenth of the sample.
In terms of educational attainment, Table 6.1 shows that the majority of PLWHAs (55 per cent) had attained primary level education, nearly one quarter had attained secondary education, and 18 per cent reported that they had never attended school. Only four per cent had received post-secondary education.
It was also important for the project to know the marital arrangements of PLWHAs. Table 6.1 shows that the majority (58 per cent) were divorced or separated; another 29 per cent were married or living together with a partner at the time of the survey. The rest either had no partner or no regular one.
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Table 6.1: Selected Socio-demographic Characteristics of the Respondents, LQAS Survey, Uganda, 2003.
Characteristic % Age: < 15 1.2 15 – 24 2.7 25 – 34 32.7 35 – 49 51.3 50 + 11.4
Educational attainment: None 17.7 Primary 55.3 Secondary 22.6 Post-secondary 4.4
Marital status: Single, no partner 8.4 Single, no regular partner 5.7 Married or living together 28.5 Widowed/divorced/ Separated 57.5 Total 100.0
Medical Care for PLWHAs
The main thrust of interventions that support PLWHAs has been the promotion of positive living. One aspect of this life style encourages PLWHAs to care for their health. This section assesses the health status of respondents and their response to bouts of sickness. The respondents were therefore asked whether they were sick at any time during the month preceding the survey. As Table 6.2 shows, more than three quarters of the PLWHAs had experienced an illness during this period. Questions asked help to assess current source of care and support as well as to assess the adequacy of the care
The next step was to find out what happened when they were ill. Table 6.2 shows that nearly all (95 per cent) of PLWHAs who fell ill received medical care. It was also important for Project purposes to establish whether people who became ill got treatment from appropriate sources, and accordingly respondents were asked to specify the person they received medical care from. From Table 6.2, it can be seen that the overwhelming majority of PLWHAs (86 per cent) received care from medical personnel, and virtually none were receiving care from traditional healers.
A final point of interest was the place where care was obtained. Table 6.2 shows that about three quarters of PLWHAs received care from a health facility, while only 10 per cent were receiving care at home from an outreach provider.
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Table 6.2: Sickness and Care-Seeking Patterns among PLWHA, LQAS Survey, Uganda, 2003.
Attribute % Confidence interval Sick 1 month before survey 78.3 2.0 Received medical care 94.5 1.3 Received care from medical personnel 85.7 1.1 Received care from health facility 72.6 2.1
Other Types of Care and Support
Other types of support the study measured were income generation, psychosocial, material, and food support – all these are areas the NSF focuses on. Regarding income generation, the study asked whether respondents had received any support in the form of training, cash, or kind. Table 6.3 demonstrates that 41 per cent of respondents had received some kind of income generation support. The most common was training, followed by the receiving of cash or in-kind support.
Regarding psychosocial support, respondents were asked whether in the month preceding the survey they had received the various kinds of help listed in Table 6.3. More than three- quarters of respondents had received some form of psychosocial support, although only 46 per cent had been visited by professional counselors at home. Sixty-four per cent had gone to counseling centres like TASO and to post-test clubs, and 37 per cent were visited at home by a person from a community support group.
In the case of material support, the study asked respondents whether they had received support in the form of beddings or clothing from any support organization, group, or project in the year preceding the survey. Only 12.5 per cent had.
A final form of support the study asked about was food. Respondents were asked whether they had received food from a support organization, group, or project in three months, one month, or in the week preceding the survey. The information in Table 6.3 shows that only 41.9 per cent of the respondents had received food support within the last three months. Depending on the need for food support for PLWHAs this is another area that may require more attention.
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Table 6.3: Percentage of PLWHAs Getting the Different Types of Support, LQAS Survey, Uganda, 2003.
Type of support % Confidence Receiving interval Income generation support: Any kind 41.2 2.40 Training 36.1 2.37 Cash or kind 22.5 1.87 Psychosocial support: Any kind 79.4 2.05 Visited by professionals 46.1 2.41 Went to counseling centre 64.0 2.37 Visited by support group 37.2 2.39 Material support: Any kind 12.5 1.54 Beddings 11.5 1.49 Clothing 4.1 0.87 Food support (prior to survey): Any food support 41.9 2.39 One week 16.4 1.71 One month 35.7 2.23 Three months 29.9 2.25
Positive Living Practices
One of the main interventions of the national response promotes for people living with HIV/AIDS is positive living, that is, actions or arrangements PLWHAs are encouraged to follow to continue living their lives as normally as possible despite being HIV positive. Accordingly, the study measured the percentage of PLWHAs who had adopted at least two positive living practices. According to the data in Table 6.4, as many as 70 per cent of the respondents were practicing at least two strategies for positive living. This is not surprising since all the respondents were registered with an organization of one kind or another and must have been taught about positive living. The surprise, rather, is that this percentage is not higher, since an essential role of organizations is to promote positive living.
“Joining a support organization” was in fact the most commonly practiced strategy (67 per cent), followed by “proper nutrition” and “making arrangements for the future care of the children,” each mentioned by half of the respondents.
Among the less commonly practiced activities for positive living were “follow-up counseling,” which was mentioned by 46 per cent of respondents, “practicing safe sex,” mentioned by 43 per cent, “learning an income generating activity (38 per cent), and “joining a post-test club” and “status disclosure” (each cited by a third).
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Table 6.4: Percentages of PLWHA Practicing the Different Types of Positive Living, LQAS Survey, Uganda, 2003.
Positive living practice % Confidence Reporting interval Joining support organization (e.g., Taso) 67.8 2.53 Joining post -test clubs or day care centres 33.0 2.55 Status disclosure/going public 33.2 2.55 Adopt safe sex (e.g., condoms, abstinence) 42.7 2.67 Join PMTCT programme 2.8 0.89 Join family planning 10.3 1.65 Will making 20.1 2.18 Writing memory books 8.4 1.50 Learning income generating activities 37.9 2.63 Attend follow-up counseling 45.7 2.69 Proper nutrition 50.1 2.70 Arrange for future care of children 52.0 2.70
Practicing 2 or more ways of positive living 70.7 2.22
Harmful Practices
Some people resort to negative or harmful practices upon learning that they are HIV positive. The project tries to discourage these practices, listed in Table 6.5, and replace them with positive ones, but it was an important part of the study to establish the prevalence of such negative practices in the study population.
Table 6.5 indicates that these practices are rarely observed in the study population. The practice of not revealing their status was cited by only three per cent of respondents, selling off property by even fewer, migrating to another area and remarrying were each mentioned by two per cent, and sending children away was mentioned by only one per cent of the respondents. We note that not revealing one’s HIV+ status and remarrying are not negative living practices, on the contrary PLWHAs are encouraged to relate if they so wish as one way of living normally though positive. Uganda uses revealing status as a strategy to reduce stigma but not necessarily as a positive living practice. It is one’s right to keep one’s own status private if they so wish.
It must be emphasized again that these are people who are already registered with support organizations. The impressive results seen in connection with the negative practices might be an indication of the success of the programmes of these organizations.
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Table 6.5: Percentages of PLWHA Practicing Different Types of Living Styles, LQAS Survey, Uganda, 2003.
Negative living practice % Confidence Reporting interval Not to reveal their status 3.3 0.97 Sale of property 2.3 0.81 Migrating to another area 1.7 0.71 Remarrying 2.0 0.75 Sending the children away 1.2 0.59
Misconceptions about HIV/AIDS
Consistent with promoting positive living and discouraging negative practices, the Project also has as one of its objectives to dispel misconceptions among PLWHAs about the mode of transmission of the virus. The study measured the level of awareness of the five most common misconceptions about transmission. The results in Table 6.6 show that only 59 per cent of respondents rejected all five misconceptions. The most widely held misconception was about the mosquito, with nearly a third of respondents believing that HIV could be transmitted by mosquitoes. This is a surprising finding because PLWHAs are exposed to correct teaching about modes of HIV transmission and should therefore have fewer misconceptions
Table 6.6: Percentage of PLWHA who Reject Common Misconceptions on HIV Transmission, LQAS Survey, Uganda, 2003.
Misconception % Confidence Rejecting interval Mosquitoes 66.9 2.80 Touching and infected 90.2 1.46 person Sharing Utensils 90.8 1.76 Sharing Toilets 88.6 1.72 Witchcraft 89.1 1.79 Rejecting all five 59.1 2.41 misconceptions
Knowledge of the ABCs of HIV/AIDS Prevention and Condom Use
It was also important to find out whether respondents knew about the methods for preventing the sexual transmission of HIV, the ABCs, which are promoted by the Project. Such knowledge is important to protect both the general population against infection and the PLWHAs themselves against reinfection. The project indicator is the percentage of PLWHAs who know at least two of the three ABCs. The results, presented in Table 6.7, indicate that 65 per cent of respondents knew at least two methods of prevention. It should be noted that as people who are already registered with an HIV/AIDS support organizations, this percentage is surprisingly low.
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The Project is also actively promoting condom use, in the general population and among PLWHAs in particular. Hence the study had an interest in finding out patterns of condom use among this group. Respondents were first asked whether they had ever used a condom and, as Table 6.7 shows, only 55 per cent had. It has to be a matter of some concern that as many as 45 per cent of people living with HIV/AIDS have never used a condom.
The study then asked PLWHAs whether they had had sex in the 12 months preceding the survey. As shown in Table 6.7, 41 per cent answered yes. To understand the risk level of this behaviour, respondents were asked whether they use condoms every time they have sex, only sometimes, or never. According to Table 6.7, only half of respondents use condoms every time they have sex; 29 per cent use condoms only sometimes; and 23 per cent admitted that they never use condoms. This finding suggests that there is a very real risk of transmission here, both to the general public and to PLWHAs. Another point of concern is that PLHWAs are not avoiding re-infection as is emphasized by positive living teachings.
Another measure of risk is condom use in the last sexual contact. When asked, only 63 per cent of the respondents reported that they had used a condom in their last act of sexual intercourse. While this percentage is higher than those using condoms regularly, it is still disappointing.
Table 6.7: Sexual Behaviour and Condom Use among PLWHA, LQAS Survey, Uganda, 2003 .
Behaviour % Reporting Confidence interval Ever used a condom 54.7 2.43 Had sex 12 month period or since learning HIV+ status 41.0 2.43 Condom use pattern in sexual contact: Always 48.7 Sometimes 28.5 3.90 Never 22.8 Used condom in last act of sexual contact 63.4 3.78
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Chapter 7: Findings of the Follow-Up Study
The LQAS study summarized in the previous chapters was intended to be the first of three phases of the Community Learning Process of the Uganda AIDS Control Project. The study set the stage for the next two phases: the diagnostic phase and the strategic thinking phase, culminating in tactical changes to improve individual programmes in individual districts. In keeping with the district-centred focus of UACP, the purpose of the last two phases was to develop the capacity of district teams to examine why current interventions do not yield expected results and identify practical solutions to any problems.
Purpose of the Follow-Up Study
Results from the LQAS identified problems in several key areas, which became the focus of the follow-up survey:
limited potential for successfully enrolling clients in PMTCT services/programs low use of VCT services by women and young people limited condom use PLWHAs not fully embracing “positive living” practices, particularly in the area of safe sex practices low levels of support for orphans
The UACP also identified limited reach of orphan care and support activities and low coverage on most indicators of knowledge, attitude and practice as a priority.
According to LQAS results, over 90 per cent of mothers reported attending ANC for their latest birth, but only 26 per cent were able to show a maternal card to the interviewer. The others either lost the cards, kept them with another person, or claimed never to have received any. Of these mothers, only 44 per cent were counseled about the possibility of reducing mother-to-child transmission of the HIV virus, just over one third (38 per cent) were counseled about taking an HIV test, and only 35 per cent of those women—or 13 per cent of all women attending ANC)—actually took the test. These results suggest that although ANC is potentially a very good entry point for PMTCT, missed opportunities are limiting the effectiveness of this approach.
To understand why these opportunities are being missed, the follow-up study:
• visited health facilities to assess their readiness to offer services and to find out why mothers are not routinely counseled about HIV testing, and • conducted focus group discussions with mothers in some communities to determine why they are not taking the HIV test.
Other LQAS results showed that among men, women, and young people in general (not just mothers) the use of VCT is likewise limited. Although 47 per cent of men and 39 per cent of women knew the benefits of VCT, only 21 and 22 per cent respectively had ever voluntarily requested an HIV test, and only 14 per cent fewer took the test. Among young people, only 40 per cent knew the VCT benefits and only 16 per cent had ever requested a test. Clearly, the Project needs to address the issue of how to motivate men, women, and especially young people to get tested for HIV.
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Regarding condom use, the percentage was lowest among women and young people. The 68 per cent of women reported never having used a condom, with more than a quarter citing the refusal of their partners as the reason. This response indicates the powerlessness experienced by women that puts them at risk of HIV infection and of the need to educate men. With respect to young people, condom use is low (one quarter always use a condom), and 70 per cent could not cite three steps for correct use of the condom.
The concern with orphan care and support is that there is so little being done. Only 15 per cent of orphans received education support in the form of school fees and scholastic materials, only four per cent received any kind of professional counseling, and only seven per cent received counseling from a community support group. Material and food support reached only 5.3 and 3.5 per cent of orphans surveyed.
The concern with PLWHAs is why more of them do not embrace safe sex practices despite being exposed to counseling on positive living.
With these issues as its focus, the follow-up study identified five overall objectives:
to assess the readiness of the locations or sites designated to provide PMTCT in targeted districts to explore the reasons behind low use of condoms among women and young people to determine what motivates women, men and young people to use VCT and what are the impediments to determine why only a few orphans are reached in those districts where orphan care and support interventions have been tried to assess why PLWHAs do not embrace safe sex practices despite exposure to positive living teachings
The follow-up study was conducted in 9 out of the 19 districts surveyed in the original LQAS study. The study population included service providers and prospective clients of a PMTCT program; women 15-49; men 15-54; young people 15 - 24; orphans 13-18, guardians of orphans 6-18, district level administrators, and managers of district HIV/AIDS programs.
Findings
Preventing MTCT
The PMTCT research issue was that despite the fact that nearly all mothers surveyed had attended ANC at least once, only 44 per cent had been counseled about PMTCT, only 38 per cent had been counseled about VCT, only 35 per cent of these mothers (or 12 per cent of all mothers) eventually got tested for HIV. These results raise several questions in light of the fact that national policy stipulates that PMTCT (including counseling on VCT) is to be integrated into ANC:
1. Why don’t pregnant women take HIV tests despite being counseled on PMTCT? 2. Is the ANC setting the best entry point for PMTCT? 3. Should information, education, and counseling (IEC) about PMTCT be provided during the period of pregnancy or before?
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4. Do men and women perceive and want a role for family members in the decision making process on PMTCT?
To find answers to these questions, discussions were held with mothers of children 0-11 months, as these were women who had recent experience of the health system, and with men aged 15-54, the likely husbands of these women and the dominant decision-makers in many families.
On the first question, why women fail to take an HIV test despite counseling, the following responses were obtained from the mothers:
Table 7. 1: Priority Responses of Mothers of Children 0-11 Months
# of districts where this response was Responses ranked among the top three Afraid of losing their marriage in case results showed that they are 6 HIV positive “When you know you are HIV positive you die very fast due to 6 frustration.” Some women cannot be bothered 3 There is no money for VCT; men only give money for illness not 3 investigations Fear of community gossip when one tests HIV positive (fear of 2 shame before neighbours) No time to undergo many medical processes while you are 1 pregnant VCT is not provided at ANC centre, it is far and we don’t have 1 money for transport The misconception that you must go with your partner; women 1 find it difficult to convince men to go
The two overriding reasons women do not take the test are: “[They are] afraid of losing their marriage in case results showed that they are HIV positive,” and “When you know that you are HIV positive, you die very fast due to frustration.” Women rank these two among the top three reasons in six out of the nine districts. The suggestion in the first response is that either the counseling only focuses on women and totally excludes their husbands, or that it fails to address the primary fears of women. Concerning the second response, it is clear that the concept of positive living is not coming through (or not being raised with) recipients of PMTCT counseling. This is an important point because these women, unlike those in general VCT programs, are not a selected subgroup that has chosen testing and are therefore already motivated.
The next pair of responses that also appear with some element of commonality across districts are: “Some women cannot be bothered (indifferent),” and “There is no money for VCT; men can only give money for illness not investigations.” Although these sentiments were expressed in only three out of the nine districts, they in fact reinforce the two reasons expressed earlier and point to a need for more information, education, and counseling in the general PMTCT environment.
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The next table reports on men’s perspective. When the question of why women do not test was put to them, men made the responses found in Table 7.2.
Table 7. 2: Responses of Men 15-54 # of districts where this response Responses was ranked among the top three: Fear of results 7 Fear of losing their marriage when 6 husband learns that they are HIV positive Fear to be seem by public and branded 2 HIV positive After all, husbands have extra marital 1 affairs Fear that medical people kill HIV positive 1 people VCT sites are far 1 Drugs are expensive; why bother 1 VCT is not rewarding; you are just 1 victimized
The most commonly reported response among the men’s groups is “Fear of VCT results,” followed by “Fear of losing their marriage when the husband learns that they [the women] are HIV positive.” Both of these responses corroborate women’s fears expressed in their responses and show a serious lack of communication and support between husbands and wives.
In order to answer whether the ANC setting is the best entry point for PMTCT, that question was put to both men and women. If they did not think of it as the best point, they were asked to name alternative setting or means through which PMTCT could be introduced. The responses of men and women are given in Tables 7.3 and 7.4 below.
Table 7.3: Responses of Mothers of Children 0-11 Months about the Best Alternative Setting to ANC to Introduce PMTCT Information
# of districts where this response Responses was ranked among the top three Village meetings 5 Radio programs 3 During religious congregations 3 Schools to target young girls 3 Mobile TV programs 1 Stand alone VCT sites 1 Workshops 1 Traditional birth attendants 1 Family planning clinics 1 Home to home campaigns 1
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Table 7.4: Responses of Men 15-54 about the Best Alternative Setting to ANC to Introduce PMTCT Information
# of districts where this response Responses was ranked among the top three Community health education 3 meetings Seminars at community level 3 Educate women from girlhood 1 Existing women for a 1 Worship places 1
It can be seen from these responses that most community members, both men and women, feel that PMTCT should be introduced in communities rather than facility-based settings. The leading response among women is that PMTCT should be introduced in village meetings and, for men, in a community health education forum or in seminars at the community level.
Respondents were also asked at what point information, education, and communication about PMTCT should be given to women. The intention here was to see whether they would support introducing this information during pregnancy. The responses of men and women are given below:
Table 7.5: Responses of Mothers of Children 0-11 Months about When PMTCT IEC Interventions Should Begin to Focus on Women
# of districts where this response Responses was ranked among the top three Before pregnancy 8 During pregnancy 6 During post-natal period 4 At time of delivery 3
Table 7.6: Responses of Men 15-54 about When PMTCT IEC Interventions Should Begin to Focus on Women
# of districts where this response Responses was ranked among the top three Before pregnancy 7 During pregnancy 7 At time of delivery 4 During post-natal period 3
The final research question on PMTCT was whether men and women perceived and wanted a role for other family members in the decision making process on PMTCT. They responded as indicated in Tables 7.7 and 7.8.
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Table 7.7: Responses of Mothers of Children 0-11 Months about Other Family Members to Include in PMTCT Decision Making
# of districts where this response Responses was ranked among the top three Husbands 9 Mother of pregnant person, 4 sisters and paternal auntie Children 12 and above years 2
Table 7.8: Responses of Men 15-54 about Other Family Members to Include in PMTCT Decision Making
# of districts where this response Responses was ranked among the top three Husbands 9 Children of the mother 3 Parents or in-laws 3 Friends 1 Elder sisters 1
Men and women in all nine of the districts surveyed indicated that husbands should be involved decisions about PMTCT.
PMTCT Facility Assessment
Another part of the follow-up survey looked at the facilities where PMTCT was being offered. PMTCT services are relatively new in Uganda and can be categorized as specialized services. For this reason they require specially trained service providers, special arrangements at point of delivery and special arrangements that link static service sites and outreach locations. The processes through which individuals eventually enrol into a PMTCT programme include a set of activities that are complementary. LQAS results show that enrolment into PMTCT is an outcome of adequate education and counseling and the availability of all complementary services. This facility assessment was to determine how ready any service site would be to influence intended outcome.
The research questions to be answered were:
1. What is it about the way services are organized that promotes or limits enrolment, access to and availability of quality PMTCT services? 2. What is it about client management that contributes to high or low use of services? 3. Are service protocols adequate in guiding quality service delivery?
To answer these questions three methods were used: interviews with service providers and site managers, observations of service delivery, and review of documents such as client registers and service provision protocols.
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In all nine assessed districts PMTCT services are located in level 5 district and regional referral hospitals, with important implications as to how many ordinary women seek services from such large establishments. According to national policy PMTCT services are supposed to be integrated into ANC, meaning the larger the client volume at ANC clinics the large the number of women who participate in PMTCT services. From the records of every facility that was assessed, client volume at ANC is relatively low and does not match the potential of the establishment.
Table 7.9: Client Volume and Trained service providers at ANC
Type and level of Facility Monthly Average # of providers Client-to - ANC per trained in provider attendees daily PMTCT ratio session provision Arua Regional Hospital 661 33 10 3:1 Iganga District Hospital 920 46 2 23:1 Kabale Regional Hospital 345 17 5 3:1 Kampala Mulago National 3035 152 11 14:1 Hospital Kayunga District Hospital 561 28 4 7:1 Masaka District Hospital 194 10 8 1:1 Masindi District Hospital 303 15 6 3:1 Mbale Regional Hospital 719 36 4 9:1 Mbarara Regional Hospital 421 21 8 3:1
As illustrated in the above table, the ratio of client to provider in Iganga, Kayunga, Mulago and Mbale is high and therefore suggests a potential work overload for skilled service providers should large proportions of women seek PMTCT services. On the other hand, in Masaka, Mbarara, Kabale and Arua the ratios are low, suggesting that for these case loads there is an under utilization of service providers. Potential PMTCT clients receive much less attention in crowded clinics and are less likely to become aware, knowledgeable about, or interested in PMTCT. Service providers are occupied with other ANC services that are provided on the same day as when PMTCT is being introduced or supposed to be provided.
It was established that all facilities that were assessed offered the whole spectrum of PMTCT services as listed in the national PMTCT policy. Arua, Kabale and Kampala had enough PMTCT supplies, but Iganga lacked VCT kits and Mbarara, Mbale and Masaka lacked iron and vitamin supplements. All facilities had a good supply of ARVs, however, apart from Masindi and Kayunga where PMTCT services are not fully established.
Counseling on PMTCT and for VCT is extremely important for individuals to decide to enrol in PMTCT programs, and counseling on and availability of ARVs increase prevention even more. The table below illustrates that not everybody counseled about ARVs ends up taking them even when they are available. Reasons why some women who are counseled on ARVs end up not taking them include low involvement and participation of male partners and the stigma associated with ARV taking.
Table 7.10: PMTCT-Related Service Use
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Facility Monthly # Took # Tested # Coun- # Provided ANC test and seled on with ARV Attendees positive ARV counseled for PMTCT Arua Hospital 470 461 13 164 11 Iganga Hospital 920 15 5 5 5 Kabale Hospital 182 75 17 183 4 Kampala, Mulago 2832 2147 190 186 186 National Hospital Kayunga Hospital 561 39 7 Referred Referred Masaka Hospital 194 74 16 14 12 Masindi Hospital 303 101 Referred Referred 13 Mbale Hospital 125 9 47 9 9 Mbarara Hospital 420 336 26 26 21
In addition to offering a complete range of PMTCT-related services, proper management of clients will also contribute to service use. Except for Arua and Kampala, other districts showed very poor response to PMTCT enrolment, probably because of the poor service environment in these facilities. The table below shows that most facilities still lack appropriate arrangements for counseling, such as a lack of doors or having only cardboard walls that are only 6 ft high.
Client waiting time is another issue; having to wait as long as five hours is too long for women who are “ambushed” with PMTCT on an ANC visit. It is likely that this is one of the reasons why women are discouraged from attending ANC at these sites.
Two districts illustrated the role of outreach in client mobilization. Facilities like Masaka, where there is no outreach, have low numbers of clients compared to Mulago Hospital, where there is an outreach programme by the university and Iganga Hospital with sixteen community workers attached to the facility.
Publicity also plays a role in making people aware of the availability of services. Over 90% of the facilities assessed did not have signposts or arrangements to announce and inform the public bout the availability of a service that is relatively new. The issue of taking PMTCT awareness-building and education outside the ANC setting was addressed in the community focus group discussions, and both mothers and men were in favour of using community meetings or other events as an opportunity to publicize PMTCT more effectively.
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Table 7.11: Service Arrangements at PMTCT Sites
Facility Privacy and Client wait time Outreach and Publicity of confidentiality referral services mechanisms Arua Client confidentiality 3 hours Outreach exists Signpost exists Hospital protected. No effort to inform Appropriate counseling public through room other means Iganga Setting not 5 hours Outreach exists, No signpost Hospital comfortable, same 16 community room used for all MCH workers attached No other services, lacks privacy to facility information given for HIV related to public services Kabale Counseling room has 5 hours Outreach exists, 3 Signpost exists but Hospital no door and walls are community poorly located just cardboards outreach workers attached Record system observes confidentiality Kampala, Counseling is done in a 4 hours Very good well No signpost but Mulago private room organized many get to know National outreach program through referrals by Hospital outreach programme Kayunga Counseling room not Not established Outreach system No publicity for all Hospital adequate for PMTCT but in place, working HIV/AIDS related 4-5 hours for well for EPI, FP, services VCT VCT Masaka Counseling room is 2 hours No outreach No publicity of any Hospital adequate kind
Masindi Hospital Proposed counseling Not assessed Outreach systems No publicity yet room adequate exist already Mbale Counseling room is 4 hours No outreach No publicity except Hospital adequate by word of mouth
Client flow very poor Mbarara Good counseling room 3-4 hours No outreach No publicity of any Hospital with privacy kind
The only guideline existing at PMTCT sites is a booklet “Guidelines for Implementation” by MOH, and those guidelines were for VCT services. There are no guidelines that specifically address PMTCT counseling.
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Condom Use
The follow-up study on condom use examined why more than two thirds of women reported never using a condom and why condom use is so low among young people. Both of these groups are specifically targeted by the national HIV/AIDS Strategic Framework and the UACP.
The research questions for this part of the study were:
1. What is the motivation behind decisions on condom use? 2. What are the communication difficulties among couples? 3. Why would men refuse to use condoms if women so wished? 4. Under what circumstances do young people have sexual affairs? 5. How conducive are these circumstances to regular and correct condom use? 6. How do young people learn about instructions on how to use a condom?
To find answers to these questions, discussions were held with women 25-49, men 15-54, and young people 15-24.
Both men and women were asked what motivates couples to discuss condom use, and answered as follows:
Table 7.12: Responses of Women 25-49 about Motivations to Use Condoms
# of districts where this response Responses was ranked among the top three When man has multiple partners and wife is 6 threatened that he may be infected When members of the community die and 5 others are bedridden and many orphans left In an outburst (quarrel) after husband has 3 been caught having sex with another woman If a couple wants to undertake VCT 2 When a man frequently comes home late at 2 night and many people around the village are infected by HIV When partner starts falling sick 1 If a woman finds condom in husband’s 1 trousers and yet they don’t use them at home When a partner lost a previous lover 1 When you get into a new sexual relationship 1
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Table 7.13: Responses of Men 25-54 about Motivations to Use Condoms
# of districts where this response Responses was ranked among the top three When sexual partner has AIDS 5 When married couples quarrel over man 5 staying out late When woman learns through rumours that 3 husband has another wife When one experiences symptoms of 3 STDs/HIV When wife returns after separation 2 Persistent illness of partner 2 After man has attended HIV/AIDS education 2 session Partner lost a previous husband 1 When discussing to undertake VCT 1 First contact with sexual partner 1
It is clear in both cases that women and men would consider discussing use of condoms only under extreme circumstances. The most common response among women is “when a man has multiple sexual partners and wife feels threatened that he may be infected with HIV,” followed by “when a member of the community dies of AIDS and others are bed-ridden.” The leading responses among men were “when a sexual partner has AIDS” and “when married couples quarrel over a man staying out late.”
It should be noted that many of these answers suggest that the discussion about condom use comes after HIV/AIDS is already suspected by one or both partners; in other words, it comes too late. IEC interventions need to stress that condoms don’t prevent the spread of AIDS if they only used after a problem has become apparent.
When the same question on communication about HIV/AIDS among couples was posed to young people, they responded as follows:
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Table 7.14: Responses of Young Women 15-24 (not married) about Motivations to Use Condoms
# of districts where this response Responses was ranked among the top three When you wish to get married and has 4 never tested When starting sexual relationship 3 When your boy friend has other girls 3 When someone you know has just died 3 If you just want to know your sero status 2 and you need partner to escort you When you have been having unprotected 2 sex and are afraid that you may be infected. When your peer has joined TASO 2 When cautioning each other to be faithful 2 When a lady is pregnant and wishes to enrol 1 in PMTCT When discussing condom use 1
Table 7.15: Responses of Young Men 15-24 (not married) about Motivations to Use Condoms
# of districts where this response Responses was ranked among the top three When people you know die of HIV 4 When you don’t trust partner 4 First contact with sexual partner 3 When your peers are down with AIDS 3 When you see friends with multiple sexual 2 partners When one experiences persistent illness 2 When negotiating use of a condom 1 When cautioning sexual partner to be faithful 1 to you alone When considering VCT 1 When intending to have many sexual partners 1
The responses give by young people on the motivation for talking about HIV/AIDS are similar to those given by older people.
It was also important to establish any difficulties couples encounter as they try to discuss using condoms or that would hinder such discussions. Men and women answered as indicated below.
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Table 7.16: Responses of Women 25-49 about Difficulties Concerning Discussion of Condom Use with Partner
# of districts where this response Responses was ranked among the top three When the male partner is very tough, he thinks you intend to blame him for being loose and likely to have HIV; you 5 can be beaten for the talk. When the male partner has other known sexual partners 2 The male partner may think you talk about HIV because 2 you have it (you are guilt) It may create misunderstandings leading to divorce 2 Because men don’t like condoms, they intimidate women 1 stopping them from talking about HIV. When partner is absent at an opportune time when the talk 1 would be easy (e.g. when his friend has died of HIV) When the relationship is strained for one reason or another 1 Fear that talk may lead to VCT 1
Table 7.17: Responses of Men 25-54 about Difficulties Concerning Discussion of Condom Use with Partner
# of districts where this response Responses was ranked among the top three When one of the sexual partners of the couple has 4 lost a spouse When your wife knows that you have other 4 sexual partners AIDS is scaring because it has no cure and it is frightening to imagine leaving your children so it 2 is better to keep quiet The one who talks first is suspected to be guilty 2 When a man suspects to be HIV positive you fear wife’s reaction and revealing to who she 2 considers sympathizers When sexual partner refuses to use condoms, demanding faithfulness, when you talk about HIV 1 you sound a betrayer
The response that stands out among the female groups is “when the male partner is very tough, he thinks you intend to blame him for being loose and likely to have HIV; you can be beaten for the talk.” It suggests that one of the biggest obstacles women face is fear of their partners’ negative response. However, the other similarly ranked response, “When one of the sexual partners of the couple has lost a spouse,” is equally important as it suggests that men and women do not have the communication skills to discuss their intimate worries and concerns with their partner.
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Young men and women 15- 24 years also reported the following obstacles to discussions about condom use.
Table 7.18: Responses of Women 15-24 about Difficulties Concerning Discussion of Condom Use with Partner
Responses # of districts where this response was ranked among the top three If you are shy 3 When a relationship is still new and the girl badly 3 needs the man When a man gives you money 3 When you are infected with HIV (either or both) 2 Fear of being misunderstood that when you talk 2 about HIV, you are infected Fearing your partner (either girl is much younger 2 or in a society where women don’t talk) Fear of disappointment in case partner is positive 1 When there is no reason or sign to suspect danger 1 If you have already had sexual intercourse 1
Table 7.19: Responses of Young Men 15-24 about Difficulties Concerning Discussion of Condom Use with Partner
Responses # of districts where this response was ranked among the top three Causes suspicion that the initiator of talk has HIV 6 Guilt due to unfaithfulness 3 Fear to loose sexual partner 3 When partner is already infected 2 HIV is associated with death 2 Controversial what one supports another repel 1 Talking of HIV leads sexual partners into deciding to use condoms and sex is for money. 1 You cannot buy a girl and buy a condom Not wanting to use a condom 1
The leading response among young men, “causes suspicion that the initiator of talk has HIV,” suggests a serious communication problem in young people’s relationships. Young women gave three equally common responses: “if you are shy,” “when a relationship is still new and the girl badly needs the man,” and “when a man gives you money.” These responses suggest a lack of self-confidence, which may lead young women to be dependent on men to the extent that they cannot confront them with anything that may be considered sensitive.
The study also wanted to find out why men would refuse to use condoms if women wished to use one. The answers given to this question by women and men are given below.
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Table 7.20: Responses of Women 25-49 about Why a Man Would Refuse to Use Condoms if a Woman Wished to Use One
# of districts where this Responses response was ranked among the top three Men insist that condoms reduce sexual pleasure 6 Men infected with HIV want to die with their wives 5 and not leaving them for other men Men may be interested in more children 5 Decisions made about sexual relationships are 1 made by men (culturally) and so is condom use When a man suspects that a woman cheats on him 1 he refuses condoms so as to infect her Men complain of tightness of condoms (they fear 1 cancer) They don’t know how to use a condom 1
Table 7.21: Responses of Men 25-54 about Why a Man Would Refuse to Use Condoms if a Woman Wished to Use One
# of districts where this Responses response was ranked among the top three Sex with a condom cuts down pleasure. They don’t 7 feel the woman’s body and yet sexual urge is high Men want children 6 If it is a new relationship (new marriage) men want 2 a body to body contact to fell ownership Misconception that condoms cause penis cancer 2 and one can lose erection Men believe condoms reduce their superiority in a relationship. It shows a man who fears the woman 1 and yet he should be boss. No time always in a hurry 1 Some are ignorant of how it looks like and works 1 they fear embarrassment before the women Misconception that condoms get stuck in vagina 1
The three responses that stand out for women are: “men insist that condoms reduce sexual pleasure,” “men infected with HIV want to die with their wives and not leave them for other men,” and “men may be interested in more children.” The leading responses from men as to why they would refuse to use a condom when their partner wanted to are: “sex with condoms cuts down pleasure,” “they don’t feel the woman’s body and yet sexual urge is high,” and “men want more children.”
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The most notable finding among these responses is that both men and women agree on the main reason why men would refuse to use condoms.
To understand the problems of condom use among young people, the study wanted to find out under what circumstances young people have sexual affairs. Young women and men described these circumstances as follows:
Table 7.22: Responses of Young Women 15-24 about Circumstances in Which Young People Have Sexual Affairs
# of districts where this Responses response was ranked among the top three When they lack money and their sexual partners 6 are willing to offer them money for sex When they congregate to watch films, to attend 4 discos, games and athletics, parties etc During puberty stage, girls are young and naïve yet their bodies want sex. They give in to any 4 available man When young women are sent on an errand in the evenings and their lovers escort them (e.g. 3 moving to shops, market) When one is staying in the same room with 2 parents Peer pressure. When others get material gains, others follow in the same footsteps, thus sexual 1 intercourse When young women visit relatives, and there is 1 less attention of elders on their movements When a husband leaves a young lady for some 1 time, e.g., men who work away from home When sleeping in a separate house from parents 1
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Table 7.23: Responses of Young Men 15-24 about Circumstances in Which Young People Have Sexual Affairs
# of districts where this response was Responses ranked among the top three During disco times 6 When girls want money and boys can give it for sex 3 Idleness/Redundant 2 Under influence of alcohol 2 On market days (a lot of idleness, alcohol-girls are let loose) 2 During circumcision period 1 While watching blue movies 1 Lust for beautiful girls (boys usually seduce them) 1 Games competition collects crowds of youth and fame end 1 late (at night) Moments when boys are not under watch and sneak out where girls are given chores need help e.g. firewood 1 collection, gardening and collecting water When youth experience parent’s sexual encounters (slums) 1 Peer pressure 1 Sexual programs (Senga) in electronic print media arouse 1 sexual feelings this prompting young men to have sex. Festival seasons were many people collect for parties and 1 elders don’t watch young people
The leading response among young women was that they commonly engage in sex when they need money, and this answer was corroborated by agreement from the men in three districts. The leading circumstance mentioned by the young men was “during discos,” (the second most common response among young women).
What emerges from young people’s responses is that the circumstances under which they engage in sex are generally unplanned and not conducive to using condoms, let alone using them correctly. The young women’s responses suggest that their circumstances often put them in weak positions from which they cannot effectively negotiate condom use even if they wanted to.
Voluntary Counseling and Testing
For women, the VCT research problem was why there is such a big gap between women’s knowledge of VCT benefits and the actual taking of an HIV test. In the case of young people, the problem was both low knowledge of benefits and low motivation to test. The specific research questions were:
1. What are the impediments to accessing and using VCT? 2. What could be done to motivate women and young people to access and take HIV tests more readily?
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To learn more about the obstacles to accessing VCT, women, men, young women, and, young men were all asked to identify their obstacles. Their responses are listed in Tables 7.24-7.27 below.
Table 7.24: Responses of Women 25-49 about Obstacles to Accessing VCT
# of districts where this Responses response was ranked among the top three Fear of results 5 Afraid of consequences especially reaction of spouses 3 Fear to be seen by community members 3 Lack of knowledge of VCT 2 Not bothered/after all no cure 2 VCT services far and no transport 2 Not sure of when and where VCT outreaches will be 1 conducted Negative attitude of health workers towards client 1 No incentives 1 Husbands deny their wives to go for VCT 1 Do not know where VCT services are conducted 1 Do not have money 1
Table 7.25: Responses of Men 25-54 about Obstacles to Accessing VCT
# of districts where this Responses response was ranked among the top three Long distance and no money for transport 4 Think that VCT services are charged highly 4 Fear reaction of family members (especially neglect) 4 Fear of results 3 Lack of knowledge on VCT 3 Misconception that when found positive you are 3 injected drugs that may kill you Not bothered after all no cure 3 Fear what people will say 3 Do not consider themselves to be at risk, therefore no 2 need for testing Think they are already infected why test 1 Do not trust that health workers give true results 1 Do not trust instruments used for testing (may give 1 false results) No help in health facilities in form of drugs even if 1 one tested
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Table 7.26: Responses of Young Women 15-24 about Obstacles to Accessing VCT
# of districts where this Responses response was ranked among the top three Fear of results 8 Fear of spreading the news about them 5 VCT service sites are far and no transport 3 Lack of money to pay for VCT services 3 Misconceptions about testing kits, fear that kits can 3 make one infertile, fear that kits are contaminated with the virus Lack of knowledge on VCT 2 Not bothered 2 Fear of loosing sexual partner 2 Misconception that AIDS symptoms is mere 1 witchcraft Attitude that am already positive why test? 1 Fear that if I test positive, the partner will say that it is 1 you who brought HIV Don’t trust health workers 1 Tribal discrimination 1 Fear to isolated 1 Lack of VCT services in the community 1 Lack of time and permission from parents 1 Fear of parent stopping paying fees if found positive 1 Sex workers fear to loose market 1
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Table 7.27: Responses of Young Men 15-24 about Obstacles to Accessing VCT
# of districts where this Responses response was ranked among the top three VCT services are far and no transport 6 Lack of knowledge on VCT 6 Fear of results 4 It is expensive 3 Don’t know where to find VCT services 2 No VCT services in community 1 Bleeding is painful 1 Fear of divorce of spouse 1 Not sure of VCT days 1 Too occupied to seek services 1 Attitude that am already positive why test? 1 Misconception that bleeding causes fainting 1 Fear of service providers 1
The leading obstacle to access to VCT voiced by women was “fear of results” which corroborates what was found in the LQAS survey. This finding means that because of the fear of the result, women tend to avoid being counseled, thereby missing an important opportunity to get their fears addressed. Because the mere possibility of a positive result scares women away from VCT, a strategy will have to developed that addresses the fear issue, possibly outside of VCT settings.
The men had three leading responses: “long distance and no money for transport,” “think that VCT services are charged highly,” and “fear of reaction of family members, especially neglect.” Men are somewhat more concerned about money than women, but both are worried about the results of finding out (and of others finding out) they are positive.
The young women were more unanimous; respondents in eight out of nine districts gave “fear of results” as the leading obstacle to accessing VCT, with a closely related reason, “fear of spreading the news about them,” as the second most common response. These two reasons reinforce the idea that the possibility of getting positive results scares young women away from VCT and that fears about stigma are still common.
The young men’s responses are somewhat different from the rest. While they too cite the problem of transport to a far away testing centre, they also cite a lack of knowledge of VCT as a leading obstacle.
The second question was what could be done to motivate women, men, and young people to take HIV tests more readily? Their responses are given in Tables 7.28-7.31 below.
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Table 7.28: Responses of Women 25-49 about What Would Motivate Them to Take an HIV Test
# of districts where this Responses response was ranked among the top three Establish VCT in community 2 Educate people about VCT 2 Provide treatment of opportunistic infections at VCT sites 2 Free services 2 Providers should be more client friendly 1 Publicity of service, time and venue 1 Government should enact a law requiring every body test 1 for HIV Provide transport to those who test 1 There should be incentives e.g. soap, food 1
Table 7.29: Responses of Men 25-54 about What Would Motivate Them to Take an HIV Test
# of districts where this Responses response was ranked among the top three VCT services should be free 4 Bring VCT services to the community 4 Educate people about VCT 4 Provide drugs and material support to those who test 1 Positive Educate community on the need to support people who 1 test positive to reduce stigma Provide free or subsidized to those who test positive 1 Promote traditional or local medicine 1 Release test results promptly 1 Counseling is effective 1 Follow up support to HIV positive clients effective 1 Limited scope by sensitisation clubs 1
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Table 7.30: Responses of Young Women 15-24 about What Would Motivate Them to Take an HIV Test
# of districts where this Responses response was ranked among the top three VCT services should be brought nearer 6 Sensitise communities about VCT 5 Reduce fee for services 3 Provide food for clients at VCT service sites 2 Health workers in government hospitals should improve 1 on attitude Provide transport 1 Offer help to orphans to encourage those who have not 1 tested Bring service providers who know local language 1
Table 7.31: Responses of Young Men 15-24
# of districts where this Responses response was ranked among the top three Increase community sensitisation on VCT 6 Bring services nearer to community (at parish level) 4 VCT should be free or charges reduced 2 Provide transport 2 Increase the number of service providers 1 Increase the number of testing sites 1 Reduce on client waiting time (give results early) 1 Providers should have a more positive attitude 1 VCT services should be regular 1
The women’s responses, though somewhat similar to what was given by the other groups, are not widely held throughout the districts. There was not substantial agreement about what were the priorities for motivating women to take a test.
The other three groups have leading proposals that are similar. The men have three common suggestions: “VCT services should be free,” “bring VCT services to the community,” “educate people about VCT”. The young men and women had two leading proposals: “increase community sensitisation on VCT” and “bring services nearer to community, say at parish level.”
People Living with HIV/AIDS
The research problem regarding people living with HIV/AIDS was that they do not fully embrace positive living practices, particularly condom use for those who were sexually active, despite their being registered and supported by AIDS support organizations. The
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National Strategic Framework views the involvement and participation of PLWHAs in the fight against AIDS as a strategy for reducing stigma and at the same time a way of promoting their rights. The failure of a large percentage of people living with HIV/AIDS to embrace the tenets of positive living would greatly undermine these strategies.
The study set out to answer the following questions:
1. Is it easy for PLWHAs to practice positive living? If not, what makes it difficult? 2. Why do PLWHAs find it difficult to use condoms and what would make it easier?
When PLWHAs were asked whether it was easy to practice positive living, respondents said that some positive living strategies were easy and others were not. Asked which practices were easy to adopt, the discussion participants listed the following:
Table 7.32: Responses of PLWHAs about Positive Living Practices that Were Easy To Adopt
# of districts where this Responses response was ranked
among the top three Medical care 6 Seeking counseling 4 Eating a balanced diet 3 Being hygienic 2 Avoiding alcohol 2 Condom use 1 Joining clubs 1 Getting support from others 1
Seeking prompt medical care was the easiest strategy to practice, followed by seeking counseling. If it’s true that PLWHAs find no particular difficulty seeking counseling (more research would have to be done), then the onus is on support organizations to package or deliver counseling in more effective ways.
When they were asked which practices were difficult to adopt, PLWHAs listed the following:
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Table 7.33: Responses of PLWHAs about Positive Living Practices That Were Difficult to Adopt
Responses # of districts where this response was ranked among the top three Abstaining from sex because it not easy to control urge 4 Avoid over working because that is how a person gets 4 money so s/he can eat Living in a hygienic environment 4 Feeding well because of poverty 3 Use of condoms because it doesn’t give pleasure 2 Getting ARV because of costs 1 Declaring status because of fear of isolation 1 Seeking treatment because of costs 1 Getting rid of worries 1
Three common practices were listed as difficult: “abstaining from sex,” “avoiding overworking,” and “living in a hygienic environment.” PLWHAs are saying that despite being positive, they still have sexual urges which are difficult to control. PLWHAs are usually advised not to engage in strenuous activities, but respondents are saying that this is the only way to maintain a livelihood. In the same way, they also admit that although they know the necessity of living in hygienic conditions, they are not always able to do so because of various handicaps.
When PLWHAs were asked why they do not use condoms, group participants gave the following reasons:
Table 7.34: Responses of PLWHAs about Why They Do Not Use Condoms
# of districts where this Responses response was ranked among the top three They want to infect others 6 Not knowing the use condoms and problems of not using them 5 (“they are already dead there is no need”) They do not know how to use them 3 Some want to produce children 3 They do not like using condoms because they do not get sexual 3 satisfaction They do not care about their lives 2 Women do not have powers to decide on condom use “order 2 natooka kwamukubwa” Misconceptions about condoms like “condoms cause cancer” 1 Some act under the influence of alcohol 1
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The striking finding here is that the number one reason (given in six out of nine districts) is “They want to infect others.” Surprising in any group, it is particularly surprising that PLWHAs would give this reason and it needs to be better understood.
There are several secondary reasons, from people in three districts, which suggest some serious underlying problems. Some people said they did not know how to use condoms, and others said they did not like using condoms because they do not get sexual satisfaction. These responses also call into question the kind of counseling and support PLWHAs are getting from their support organizations. Moreover, if the registered PLWHAs have this mentality, then one wonders what the behaviour, attitude, and practices are of other PLWHAs who are not currently being served by any organization.
What is perhaps most telling in all of this is that when PLWHAs were asked what could be done to make it easier for them to use condoms, the overwhelming response (eight out of nine districts) was, “education about proper use and benefits.” (Table 7.35) This is very close to a cry for help, which should be heeded by the Project.
Table 7.35: Responses of PLWHAs about What Could Be Done To Make It Easier for Them To Use Condoms
# of districts where this Responses response was ranked among the top three Education about proper use and benefits 8 Identify and train distributors 2 Supplies should be increased and be free 2 Train men who will train their peers on importance of condom use 2 among PLWHAs Put condoms in appropriate places 1 Religious leaders should be involved in counseling on condom use 1 Use appropriate IEC on condom use 1
PLWHA Service Facility Assessment
A subset of findings deals with the facilities which serve PLWHAs. The goal of programs providing care and support to PLWHAs is to contribute to increasing the productive life of a PLWHA. Services that target PLWHAs are categorized as specialized, requiring providers with specialized competencies, service sites that met special physical structural standards, and efficient management of clients. LQAS results suggested the need to assess the quality of services gauging from the supplier’ side to determine how ready or efficient could a service site be to influence intended behaviour outcomes.
The research questions to be answered were:
1. Does the service centre provide adequate counseling to support PLWHAs to embrace positive living? 2. Does the service centre provide opportunities to engage PLWHAs in activities that promote positive living?
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To answer these questions three methods were used; interviews with service providers and site managers, observations of service delivery, and review of documents such as client registers and service provision protocols.
It was found in all sites that were assessed that individuals who sought support from organizations receive counseling on their first contact after they were enrolled or registered as members. On all subsequent visits they come for particular services such as medical help, VCT, to join a post-test club, welfare or, benefits from income-generating activities (IGAs). For each of these services clients receive counseling related to the specific service they seek. This means that general counseling on positive living is not routinely provided. In focus group discussions with PLWHAs, it was noted that the initial counseling on positive living at enrolment comes at a time when the individual is traumatized on learning his or her positive status. The subsequent lack of continuous counseling means that PLWHAs do not internalise the concept of positive living.
The staffing level displayed in the table below makes the situation noted above even worse. According to the national service policy guidelines on HIV/AIDS counseling, the ideal client provider ratio is 6:1. The table below shows that only Rubaga Hospital has a ratio within the recommended range; in the other service sites the ratios range from 7:1 in Kayunga Hospital to 17:1 in Mbarara TASO and 35:1 in Arua NACHOLA. The high ratios raise questions about the quality of counseling.
Table 7.36: Client Volume and Trained Service Providers at PLWHA Service Sites
Type and level of # of Average # of trained Ratio Client facility PLWHAs clients service client/ wait served per per daily providers trained time month session providers Arua – 280 70 2 & 40 35:1 4 hours NACHOLA site counseling Aides Iganga Hospital 58 3 7 Less than 1 hour one Kabale – NGO 1891 94 7 13:1 20 minutes Rubaga Hospital - 268 13 10 1.3: 1 8 hours Home Care NGO Kayunga Hospital 16 15 7:1 8 hours 98 Masaka Hospital 779 195 20 10:1 5 hours Masindi Hospital Not Not Not assessed Not assessed Not assessed assessed assessed Mbale – TASO 1251 63 6 10:1 4 hours Mbarara - TASO 786 262 15 17:1 2 hours
When it comes to educational services, it was found that in all sites group education is provided on every clinic day as can been seen in the table below. However, educational materials for use by clients at site are not available in six out of eight sites while in the remaining three, materials are available but they are not sufficient as they are not in the vernacular (local language). In addition there are no take home materials for clients at all
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sites. Further more, in all cases no single material was found to be addressing messages that are specifically re-enforcing positive living.
Table 7.37: PLWHA Educational Services
TYPE AND LEVEL PLHWA education Services OF FACILITY Arua, NACHOLA Group education twice a week site Educational materials exist on site No take-home materials for clients Iganga Hospital Group education is provided on every clinic day Some educational materials but not in local language No take home materials for clients Kabale, NGO Group education provided on site on clinic days
No educational materials for provider No client take home Facility has outreach services attached Rubaga Hospital, Educational materials are very few & only in English Home Care NGO No materials for clients to take home Facility conducts group discussions by a trained facilitator. Kayunga Hospital No educational materials Facility has a TV set No materials for clients to take home No information/counseling offsite Conducts group discussions by trained facilitator Day care PLWHAs are trained Masaka Hospital Educational materials exist but not sufficient Clients access information/counseling offsite through home visits No materials for clients to take home Masindi Hospital Not assessed Mbale , TASO Sufficient educational materials (T.V, pamphlets, newsletters and posters) No materials for clients to take home Conduct group discussions by trained facilitator Clients access information /counseling offsite through home visits & outreaches. Mbarara, TASO Sufficient educational materials on site through not in local language No materials for clients to take home Conducts group discussions by trained facilitator
Counseling would be re-enforced or complemented by emotional support and welfare support, in the form of post-test clubs, IGA support, a memory book project, and nutrition promotion activities. Post-test clubs exist in all sites except Masaka and Mbarara TASO, and opportunities for income-generating activities and gainful employment exist in all sites except Kabale.
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Orphan Care and Support
Although there is no single district in Uganda where the unmet need for orphan care and support has been estimated, judging from national projections current interventions have reached very few orphans in any single district surveyed. The diagnostic study therefore focused on assessing institutional arrangements that either promote or hamper effective mobilization of communities and implementers of orphan care and support, proper identification of beneficiaries, effective allocation of available resources to address need, and provision of technical assistance to DHAC and CHAI groups.
The research questions to be answered were:
1. Do districts have orphan care and support interventions? 2. How is coverage of orphan care and support decided on and beneficiaries identified? 3. How are implementing organizations identified, selected, and engaged? 4. What determines resource allocation? How are subprojects identified, appraised and approved?
To answer these questions, discussions were held with four key informants selected from DHAC members: district HIV/AIDS focal persons, a representative of the district executive, a representative of NGOs in the district, and a representative of the heads of departments responsible for overseeing orphan care interventions.
In all districts there are only 2-3 district-level orphan and vulnerable children interventions (with geographical coverage of at least a county); the rest are CHAIs. Coverage of CHAI interventions varies from the lowest of 0.6 per cent in Arua to the highest of 7.2 per cent in Kabale. District-level interventions are implemented by large organizations like TASO, UWESO, Save the Children, Compassion, and missions such as COU and the Catholic mission.
Selecting and identifying orphans in the districts happens informally, such as when guardians register them at schools, when a concerned community group learns of a funding opportunity and takes the responsibility to identify them, through documentation available at PLWHA service organizations, or when community leaders are asked to identify them whenever support is available. In all the districts assessed there is no formal registry for orphans who are eligible for support; consequently, interventions are often planned without any knowledge of the magnitude of the problem.
None of the nine districts had criteria for identifying and selecting organizations to be responsible for providing care and support to a particular geographical catchment area. This is the case even with those organizations that do not their have own resources but seek funding from district budgets. A notable exception is Kabale where a strategy was used to mobilize communities and groups in all subcounties of the district. As a result the number and distribution of community groups caring for orphans in Kabale covers every parish and includes different types of groups, such as women cultivation groups, corporative societies, widows groups, PLWHA groups, church-based groups, and community development groups.
In all districts that are supported by UACP, DHAC is the structure responsible for spearheading the planning of HIV/AIDS programs. This assessment found that in all nine
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districts the system used to identify, select, appraise and approve funding proposals for the last two years has been a “first come, first served” approach. Implementing organizations become aware of a funding opportunity, and they work with respective communities and come up with a proposal. DHAC receives proposals and appraises and approves them, using proposal development guidelines provided by UACP. However, subproject review does not follow technical standards in terms of specificity of objectives, expected measurable outputs, or target outcomes and how these align with the NSF. A district therefore ends up allocating resources according to what communities ask for rather than according to identified needs or priorities.
As a result of not having criteria for identifying implementing organizations and not knowing what the priorities are, current community mobilization strategies do not always take advantage of the capacity that is available in reputable implementing organizations such as NGOs and CBOs.
Table 7.38: Coverage of OVC Interventions Supported by UACP in Nine Districts Included in Programme Diagnostics
District Total # of Total # of Total # of Coverage by villages in a CHAI CHAI projects CHAI projects district villages in implementing district OVC Arua 2032 15 12 0.6% Iganga 731 19 19 2.6% Kabale 652 47 47 7.2% Kampala 1498 23 19 1.3% Kayunga 337 11 9 2.7% Masaka 1079 60 41 3.8% Masindi 417 20 11 2.6% Mbale 874 19 17 1.9% Mbarara 1164 13 8 0.7%
Community Level HIV/AIDS Education and Promotion
Findings from LQAS suggest that generally speaking district coverage on most of the indicators on knowledge, attitude and practice are low despite intensive efforts through mass communication and print media by many players.
The study focused on assessing institutional arrangements at the district level that promote or hamper effective planning, community mobilization, and implementation of HIV/AIDS communication interventions.
The research questions to be answered were:
1. Do districts have specific HIV/AIDS communications interventions? 2. How are coverage and target groups for IEC decided on? 3. Do beneficiaries participate in planning and implementing? 4. How are implementing organizations identified, selected and engaged?
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5. What determines resource allocation? How are communication subprojects identified, appraised and approved?
To answer these research questions, discussions were held with four key informants selected from DHAC members: district HIV/AIDS focal persons, a representative of the district executive, a representative of NGOs in the district, and a representative of the Heads of Departments connected with overseeing HIV/AIDS communication interventions.
It was found that HIV/AIDS prevention communication interventions with district coverage (at least a county) are very few. There are 2-3 district level IEC interventions, mainly distribution of IEC materials, and occasional radio programme on local FM stations, and sensitisation workshops and seminars. Community-level efforts such as door-to-do IEC activities, group education, and large-scale IEC events with music and drama target small pockets of the population. Such events are many in number but limited in coverage. Except for efforts such as those by the Straight Talk Foundation, most interventions do not have specific communication objectives, primary audiences are not specified, and the messages don’t necessarily address specific problem whose solution is a communication intervention. Eighty percent of interventions in all district-level programs are limited to sensitisation and do not go beyond creating awareness.
Table 7.39: Coverage of UACP-Supported IEC Interventions in Nine Districts Included in Programme Diagnostics
District Total # of Total CHAI Total # of CHAI Coverage by villages villages implementing CHAI projects IEC Arua 2032 15 13 0.6% Iganga 731 19 16 2.2% Kabale 652 47 23 3.5% Kampala 1498 23 20 1.3% Kayunga 337 11 7 2.1% Masaka 1079 60 45 4.2% Masindi 417 20 20 4.8% Mbale 874 19 18 2.1% Mbarara 1164 13 11 0.9%
It was found that in all districts beneficiaries such as PLWHAs and young people participate in designing and carrying out IEC activities. Some CHAI -level IEC groups are PLWHA groups, and some young people are organized in school clubs that distribute IEC materials and contribute to Straight Talk and Young Talk Magazine (distributed to school children).
Although NGOs and CBOs with experience and capacity to implement communication strategies do exist, districts have not made good use of this expertise. None of the nine districts have criteria to guide mobilization or to identify and select organizations to implement HIV/AIDS communication strategies. Most community IEC interventions are carried out by CHAI groups, whereby communities take the responsibility to propose what they wish to do. Funding appears to be based on the approach of “first come first served.”
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The districts did not have a communication plan for identifying, selecting or allocating resources to potential implementing partners. Each district therefore ends up allocating resources according to whatever communities ask for rather than according to identified needs or priorities.
Methods
Study Area
This study was essentially a follow-up on certain problem areas identified in the LQAS study. It was conducted in 9 out of the 19 districts where LQAS has been applied. The study population included service providers and prospective clients of a PMTCT program; women 15-49; men 15-54; young people 15 -24; orphans 13-18, guardians of orphans 6-18, district level administrators, and managers of district HIV/AIDS programs.
Two criteria were used in selecting the study districts: the selected districts had to be in the first phase of implementation (in order to reach programmes that had been in business the longest) and there had to be geographical representation. The original idea here had been to select two districts from each of the four regions: Central, Eastern, Northern, and Western. In the end only one district, Arua, was selected from the Northern region because Lira was inaccessible, and Mbarara was added because it has one of the highest HIV prevalence rates in the country. Kampala made the 9th district.
Within each district, counties as supervision areas were selected on the basis of their performance in the different thematic areas. The poorest performing county on any given indicator was selected for investigation, but in the case of PMTCT, the selected county had to have a site. In case of more than one site in a district, the oldest site was selected. After selecting the counties, villages were selected randomly from the pool of villages in the county.
Capacity to Undertake the Study
The study required putting together a team at the national level to provide technical oversight and guidance and teams at the district level to undertake actual implementation. At the national level the UACP assembled a team comprising of PCT members and TRNs. Each district assembled a team of six people with prior training in LQAS as well as experience in formative research methods. With technical assistance from GAMET, UACP organized and conducted a six-day training for the central team and teams from the nine districts.
A total of 68 people were trained and deployed to conduct the assessment. In addition to the central PCT members and approximately four people from the local government departments of each district, 23 organizations participated in the training.
Study Methods and Target Groups
Data collection was undertaken through four methods: facility assessment, key informant interviews, focus group discussions, and document review.
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Facility Assessment
Facilities that have been designated to offer PMTCT were assessed on how ready they are to offer this service. Facilities serving people living with HIV/AIDS were assessed on appropriateness and comprehensiveness of the counseling and education services they are providing. Structured assessment tools were developed for this purpose.
Key Informant Interviews
Key informants provided information on institutional arrangements for orphan care and support in the districts.
Four key informants on orphan care and support were selected from DHAC members, and two key informants on PLWHAs were targeted in each district. These were service providers for both medical care and counseling services.
In addition, two key informants on PMTCT were selected from a PMTCT site in each district. The two were a manager of PMTCT services and a service provider at a PMTCT site.
Focus Group Discussions
Group discussions were organized on each of the following themes, as identified in the LQAS survey:
• VCT • PMTCT • Condom use • Care and support for PLWHAs
These themes were discussed among each target population segment:
• VCT: 4 groups per county, broken down as males 15-24 and 25-54 and females 15-24 and 25-49. • PMTCT: 4 groups distributed as young male 15-24, young female 15-24, mothers of children 0-11 months, and men 25-54. • Condom use: males 15-24 and 25-54 and females 15-24 and 25-49. • Care and support for PLWHAs: one group from one service organization in each district.
Each discussion group was made up 8-10 people selected from the community according to the relevant selection criteria. A moderator assisted by a note-taker using a structured discussion guide led the discussions. For the key questions, group participants were asked to generate responses which the note-taker wrote down on a flip chart. Using preferential ranking, the participants prioritised among their responses to produce the top three highly weighted items on that question. The top three responses from each group were pooled and compared to produce the district response profile, while the district response profiles were compiled to generate the national-level analysis. These priorities are what form the basis of the results presented in the Tables.
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The study completed a total of ninety-nine focus group discussions, nine district-level assessments, nine facility assessments at PMTCT sites, and nine assessments of sites of those organizations providing services to PLWHAs.
Document Review
The review of documents focused on examining registers and service provision protocols used in the different service areas. The key documents reviewed were:
• Service registers • Service guidelines and protocols
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Chapter 8: LQAS Principle and Method
Currently Ugandan institutions are developing effective ways to manage a diverse and decentralized response to HIV/AIDS —learning as they go. The Uganda AIDS Control Project (UACP) has placed a high priority on determining which models are effective change agents for knowledge, attitudes, and practices. It is equally interested in determining whether programme resources are being effectively used. To achieve these ends, UACP established a decentralized programme monitoring and evaluation (M&E) system. At the present time, UACP’s system is confined to tracking resource allocation, the use of services, and the management of funding. However, the UACP is also in the process of strengthening M&E systems that measure programme outcomes, which is the basis of the study described in this report.
The approach presented here, Lot Quality Assurance Sampling (LQAS), differs from classic M&E approaches that tend to be implemented by external experts and engage local programme managers or beneficiaries in the monitoring process. The LQAS approach is consistent with the contemporary thinking that recognizes the importance of engaging local people in monitoring and evaluation. By using this approach, UACP is being explicit that M&E should be used by local managers to steer and guide their programs by making tactical changes when they are needed.
Principles
LQAS is a method derived from industrial quality control procedures. Rather than collecting information to calculate a coverage proportion for an indicator, LQAS measures whether a programme catchment area has reached a performance target.
The primary role of LQAS is to serve as a performance assessment tool for managers at the implementation level and secondly to provide data for national and donor reporting. LQAS data will aid local managers to understand the status of their programs by establishing a baseline measure for key indicators of performance and quality of HIV/AIDS interventions. As LQAS is a tool that can be used on an annual basis, the UACP will support the districts to set annual targets for continuous assessment of their own performance, and to make tactical changes when needed based on lessons learned and best practices discovered in their own districts or in neighbouring districts.
In Uganda LQAS has been renamed the Local Quality Assurance and Supervision method. The UACP introduced LQAS because of the added value it brings the project as a participatory M&E approach. For example LQAS:
Creates a means through which communities and districts can share and learn from each other about what tactics work and what tactics don’t work.
Makes project planning, monitoring, and evaluation processes transparent to local people whereby they understand better the “outsiders” intention and clarify their situation to government and external supporters.
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Provides opportunities for visual sharing whereby information is presented in diagrams, maps, and other forms that are easily understood by local people, permitting participation in discussions of people who can’t read and write.
Generates information that can be used in advocacy efforts which can create a supportive policy and programme environment for implementing HIV/AIDS initiatives.
Builds an evidence database for public accountability of implementing partners.
Provides opportunities for implementing organizations to feed information back to districts and the UACP on a continuous basis to improve the quality of services.
Supports the decentralization effort and diversity, whereby each respective community or district can determine what fits its specific needs.
LQAS is an analytical tool used to judge whether selected outcome indicators have reached their performance targets. It only shows where performance is judged as having reached the benchmark and where it has not, but it does not tell symptoms and reasons why performance is below the benchmark.1 Further, LQAS detects extremes in performance. The closer the performance of a supervision area is to the performance benchmark, the more likely it is to be judged as having reached it. The further away performance is from the benchmark, the more likely it will be rejected as not having reached the target.
There are essential guiding principles for LQAS in relation to how it should be structured, methods of implementation, resource requirements, and linkages. LQAS should be:
Complementary and linked to other monitoring and evaluation efforts.
Managed by the districts and targeted communities to maximize responsibilities of implementing groups and organizations.
A self-assessment that generates and provides information that is useful to managers, from collection to utilization, or that leads to actions.
Implemented using locally available materials and resources, using existing skills and capabilities with the aim of further strengthening such skills.
Self sustaining after initial external investment, hence affordable by and accessible to the community.
A system that is linked upwards and provides feedback downwards.
1 LQAS is an hypothesis test used to judge whether a supervision area has reached a performance benchmark using cumulative probabilities of binomials.
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Methods
The Sample
The study was carried out in 19 out of 30 MAP districts, where the project has been actively implementing programs for the last two years. The study focused on six population groups targeted by the programs: men 15-54, women 15-49, young people 15-24, mothers of children 0-11 months, orphans 6-18, and PLWHAs. The community education component in both the district programme and CHAI targets men 15-54, women 15-49, mothers of children 0-11 months, and youths 15-24 for HIV/AIDS prevention education and to promote the use of HIV/AIDS-related services. Orphans and PLWHAs are the primary target for care and support services.
The criteria used in identifying the 19 districts are as follow:
Inclusion of all districts in phase one implementation of MAP with district and CHAI projects that have run for more than two years.
All districts from a group of districts in the phase two implementation of MAP where district level interventions and CHAI projects have run for at least one year.
Randomly selected districts from a group of districts where MAP is just beginning implementation.
Districts that satisfied any of the above criteria but had security problems were eliminated from the study. For the third set, regional representation was a consideration, making sure that each of the four regions of Uganda was well represented.
In each of the 19 districts, it was expected that for each of the six study groups a total of not less than 95 respondents would be studied. On average each district had about 110 respondents in each study group.
Sampling at the District Level
LQAS methodology uses small random samples. In Uganda sampling for LQAS began by identifying a geographical area called a “supervision area” where data could be collected, analysed and interpreted to form an opinion about the performance of a programme using specific indicators. Supervision areas for LQAS in Uganda districts are the administrative units called counties.
In order to develop the sample frame, each district needed to define its HIV/AIDS programme catchment area. This means that a list of all villages in each district were generated and then divided into two groups. One group consisted of villages with or targeted for HIV/AIDS intervention, and another group consisted of villages without any HIV/AIDS intervention.
Lists of villages with intervention for a respective district were categorized by county, with its corresponding population size. A list of villages without interventions was also developed and formed a control county. An LQAS sample of 19 respondents was sampled from each intervention and control county using probability proportional to size sampling. While this
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procedure was used to sample respondents for five of the client universes included in this assessment, PLWHAs were sampled using a different sampling frame, namely, registers of the service organizations to which they belonged.
For the five other client universes, in every district, households were randomly selected from the villages included in the sample from each supervision area. In order to identify respondents for each of the five groups studied—men aged 15-54, women 15-49, orphan 6- 18, and young people 15-24—the approach was to randomly select the first household using either updated household lists or a hand drawn map from which respondents were then randomly selected.
Selecting and Training Interviewers
In principle, applying LQAS at the district level was the direct responsibility of organizations or local government departments providing or managing HIV/AIDS services in their respective districts. Since LQAS is a strategy for change in programs that are not meeting desired objectives or outcomes, the rationale for engaging implementing organization in managing the implementation of LQAS is based on the fact that these managers are the primary users of the findings.
The following are criteria that guided the selection of organizations assigned to participate in the LQAS assessment of supervision areas.
The organization should be managing or providing services in the district and its operations should not have begun less than twelve months preceding the LQAS mission.
The selected CSO shall have at least two years proven experience in working with communities on HIV/AIDS.
The organization should be in a position to release or designate 1-2 officers for this LQAS exercise.
The organization should be willing to invest or contribute its own resources to future LQAS applications.
Special consideration may be given to the already engaged CSOs who are currently mobilizing and supervising community HIV/AIDS activities within the district.
Candidates from the CSO should:
Have at least a basic education, preferably Ordinary level.
Be officers who are actively engaged in HIV/AIDS community programs, and the organization must be ready to release them for 21 days.
Preferably be knowledgeable and experienced in community management concepts and approaches such as PRA.
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Preferably have experience in community surveys and various techniques used in community diagnosis.
Training
Four training workshops were organized, each consisting of teams from four to five districts and having about 70 to 80 participants each. The LQAS training is outlined in two publications entitled Assessing Community Health Programs: A Trainer’s Guide and Assessing Community Health Programs: A Participants Manual and Workbook.
The training objectives are that by the end of the LQAS Training Workshop and survey, the participants will have:
Become able to competently use the survey questionnaires. Known and applied the basic principles and concepts of LQAS. Known how to design and use sampling frames to randomly sample houses for surveys. Improved their knowledge about interviewing techniques. Conducted a Monitoring Survey, assessing knowledge, practice, and coverage on key indicators. Tabulated and analysed the LQAS data. Gained the necessary knowledge to identify priorities and use the results for improving their projects.
Data Collection
Data was collected through in-depth structured interviews of the six types of respondents. Main data collecting tools were six mini-questionnaires representing the six targeted populations. These questionnaires generated information for the following outcome indicators:
Orphan Development, Care and Support
The percentage of orphans that received medical care in the last one month of all orphans who required medical care.
The percentage of who received educational support in the last year.
The percentage of who attended five days of school in the preceding week.
The percentage of orphans who have received psychosocial support in the last month.
The percentage of orphans who received material support in the last 12 months.
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Care and Support for People Living With HIV/AIDS
The percentage of PLWHAs registered with service organizations who required medical care in the last month and received it.
The percentage of PLWHAs registered with service organizations supported for income generating activities.
The percentage of PLWHAs registered with service organizations who received psychosocial support services in the last one month.
The percentage of PLWHAs registered with service organizations who received material support in the last 12 months.
The percentage of PLWHAs who correctly identified at least two safe coping mechanisms to live positively with HIV/AIDS.
VCT
The percentage of women aged 15-49 and men aged 15-54 who know at least two benefits of VCT.
The percentage of women aged 15-49 and men aged 15-54 who have ever voluntarily requested an HIV test, received the test, and received the results.
PMTCT
The percentage of women with children aged 0-11 months who know that HIV/AIDS can be transmitted from mother to child.
The percentage of women with children aged 0-11 months who know that HIV transmission from the mother to child can be reduced.
The percentage of women aged 15-49 and men aged 15-54 who know about PMTCT.
The percentage of women with children aged 0-11 months who were counseled about PMTCT and to take an HIV test during an antenatal care visit.
The percentage of women with children aged 0-11 months who were counseled for VCT/PMTCT services who tested for HIV.
The percentage of women with children aged 0-11 months who delivered their babies in a health facility or with a clinician.
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Behavioural Change : Young People Aged 15-24
The percentage of young people aged 15-24 years who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission.
The median age at which young people aged 15-24 had first penetrative sex.
The percentage of young people aged 15-24 years who are sexually active who have ever used a condom.
The percentage of young people aged 15-24 years reporting the use of a condom during sexual intercourse with a non-regular sexual partner.
The percentage of young people aged 15-24 years who used a condom in the last act of sexual intercourse.
Behavioural Change: Women 15-49 and Men 15-54
The percentage of sexually active people (women 15-49 years and men 15-54 years) who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission.
The percentage of sexually active people (women 15-49 years and men 15-54 years) who had sex with a non-regular partner in the last 12 months.
The percentage of sexually active people (women 15-49 years and men 15-54 years) who have ever used a condom.
The percentage of sexually active people (women 15-49 years and men 15-54 years) who used a condom during sex with a non-regular partner in the last 12 months.
The percentage of sexually active people (women 15-49 years and men 15-54 years) who had used a condom in the last act of sexual intercourse with a non- regular partner.
Sexually Transmitted Infections
The percentage of sexually active people (women 15-49 years, men 15-54 years, youths 15-24 years) who both correctly identify common symptoms of STIs.
The percentage of sexually active people (women 15-49 years, men 15-54 years, youths 15-24 years) who correctly identify at least two ways of preventing transmission of HIV.
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Data Analysis
Data analysis focused on the objectives of the assessment and were tabulated to show desired outcomes at all levels. Analysis was made at three levels: county, district, and national. Analysis at county and district level is important mostly for informing management decisions, while national-level analysis is mainly for reporting purposes. Each district team analysed their data within 48 hours of completing data collection, using pre-prepared tables, pen, and pencil. Reports using these hand-tabulated results were presented to DHACs within a week of the hand tabulation so that the diagnostic process of local priority interventions could immediately begin.
Thereafter, data were entered into a computer database for analysis using SPSS. The computer analysis of the data is what has been reported in this document.
Overview of LQAS Implementation
The process of introducing and implementing LQAS starts before actual field work because it is a process which includes consultative meetings to get every stakeholder on board, building consensus on what indicators should be assessed, who is to participate in actual field work, and orienting district teams to this new approach to M&E. The entire implementation plan includes the following activities:
1. LQAS orientation and consultative meetings at national level (sectoral ministries, national CSOs, research institutions)
2. LQAS orientation workshop for DHAC team (1/2 day).
3. One day exercise to generate lists showing villages that are currently being targeted for HIV/AIDS interventions and those that are not targeted.
4. Sampling session/exercise which also included training or transferring skills to district team members (1 day).
5. Generating household lists for all included in the sample.
6. Training of district teams in LQAS methodology (5 days).
7. Data collection and analysis at county level (5-6 days).
8. Data analysis at district level (4-days).
9. Report to the DHAC (1 day).
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ANNEX 1: LQAS Principles for Programme Monitoring
UACP used LQAS to collect and analyse community -level baseline and monitoring data to plan and manage community-based programs. Although LQAS is being used with increasing frequency by public health practitioners (Robertson et al., 1997), we summarize basic principles for readers unfamiliar with it.
LQAS was developed in the 1920s (Dodge and Romig, 1944) as an industrial quality control method to assess industrial batch production (Valadez, 1991, Stroh, 1985, Reinke, 1988). The basic principle is that a line supervisor takes a small random sample of a recently manufactured batch of goods from a production unit such as an assembly line. If the number of defective goods in the sample exceeds a predetermined number, then the lot is rejected; otherwise it is accepted. This allowable number is called the decision rule (DR). DR is determined statistically (Dodge and Romig, 1944, Lwanga and Lemeshow, 1991, Valadez, 1991) based on a production standard and sample size. The sample size is set so that a manager has a high probability both of accepting lots in which a predetermined proportion of the goods are of high quality (specificity) and of rejecting lots that fail to reach a minimum production standard (sensitivity) (Valadez, 1991, Robertson et al., 1997, Wolfe and Black, 1989). The former production standard is called an upper threshold while the latter is called the lower threshold. In recent years the DR has been redefined to be the minimum number of acceptable goods—the definition used in Uganda—because health workers find the data easier to interpret.
A similar principle is used for monitoring community health programs. A manager organizes the communities in the project area into management units called a supervision area (SA), each one being the responsibility of a supervisor. In the case of UACP, the SAs are the counties within each district. The control SA was formed of villages not targeted by the UAC. The SA is analogous to the assembly line production unit in the industrial context.
The manager then selects a performance standard. This could be an annual target for each key indicator that management expects SAs to reach, or the manager may want to identify SAs that perform below average. This use of LQAS is described later. Both of these types of performance standards were used by UACP and are explained in more detail below. Annual targets are often set for each key indicator by the manager alone or with a team of supervisors, and based on the increase in an indicator’s value expected in a defined amount of time. In the case of UACP, it is yet to set programme targets. However, managers using this first LQAS study can determine how well the district programs are progressing and set 2004 targets. For further discussion on different applications of LQAS the reader can refer to any one of several texts (Duncan, 1986).
Next each supervisor carries out a small sample survey in their SA. A random sample size of 19 household interviews was used because it is the smallest sample size where the sensitivities and specificities are at least 90% for performance targets of 20%-95% when there is a 30% difference between upper and lower thresholds. This application has been used in international health since 1986 (Valadez et al., 1986, Valadez, 1991, Valadez et al., 1996, Valadez et al., 2001, Valadez and Devkota, 2002, Campos et al., 2002) and was also adopted by UACP. After a supervisor completes data collection, s/he hand-tabulates the results for his/her SA and uses a decision rule table (recently developed for local use and field
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tested internationally by several organizations) (Valadez et al., 2003) to select the appropriate decision rule for a given indicator’s target, and to decide whether his/her SA has reached it.
Thereafter, the small samples from all SAs are added together (weighted by SA population size) to calculate a weighted coverage proportion for the county catchment area. While the SA-level LQAS data are useful for supervisors to make management decisions in their areas, the aggregate measure is useful for reporting to higher administrative levels and to donors. The aggregate indicator proportion is also used to make an LQAS judgment about whether an SA is below average. The indicator proportion is rounded to the next 5% coverage proportion interval (e.g., 43% is rounded to 45%}. A decision rule is selected from the LQAS table by using the coverage proportion as the performance standard. If the minimum number of clients in the sample, stipulated in the decision rule do not have the expected behaviour, the supervisor judges the SA to be below average.
Supervisors compare their results for key indicators and modify the intervention tactics in SAs not reaching the annual target or that are below average. LQAS therefore permits the different supervisors to aid each other and benefit from lessons learned in more successful SAs.
Districts divided their catchment areas into SAs with each one managed by a supervising organization (often a local NGO). The number of SAs depended on the number of counties. However, not all villages in the counties were targeted by HIV/AIDS intervention. In each district, any village that was not targeted by a particular implementing agency or organization were aggregated into a control county.
Two characteristics have made LQAS attractive to managers. Firstly, supervisors collect only a small sample in a supervision area (n=19) to judge whether coverage for a given indicator has reached a predetermined target or is at least of average quality. Therefore, data collection does not seriously compete for time, which would otherwise be allocated to health service provision.
Secondly, the sampling procedures and analyses are simple. As LQAS was originally intended for use by factory supervisors, these procedures were feasible for a minimally educated person to carry out. Supervisors of community health workers are typically more educated than the line supervisor of yesteryear. Yet this benefit is still welcome to overworked supervisors who need easy-to-use management tools that can easily be understood within their own cultural context.
Another feature of LQAS is that data from individual SAs can be combined into a coverage proportion for an entire programme area. Added together the SA data form a stratified random sample of an entire project area. Weighting the result by the population size of each SA can increase the accuracy of the estimate by avoiding bias created by summing data collected from SAs of different sizes. This coverage estimate usually has greater precision than the one obtained with the 30-cluster method (Henderson and Sundaresan, 1982) (the other commonly used sampling method) because stratified random samples generally have narrower confidence intervals than cluster samples of the same size. This is because some subjects are selected from each and every strata, making it impossible to miss some strata completely (Robertson et al., 1997). In operational terms, the strata are the SAs. Also, LQAS does not have a design effect, which for cluster samples is assumed to be two, due to
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the intra-cluster correlation resulting from choosing contiguous households within clusters (Henderson and Sundaresan, 1982).
LQAS was ideal for UAC as local county supervisors could collect and analyse data, and do so without external (expensive) data collectors or consultants. Data were in a form that could be used for management decision-making immediately after they were collected using paper and pencil analysis methods. Later, UAC entered data into a computer to report results to donors, relevant ministries, and international agencies. Those results are contained in this report. However, it is worth repeating that this report of May 2003, is disseminated 6 months after the data were collected and reported to DHACs by their teams who participated in the LQAS assessment. Therefore, the development and programme management process was not delayed by the data entry activities. It is this feature of the LQAS approach which also sets it apart from other M&E approaches.
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Appendices
Appendix A. Key Men’s Indicators by District
Table A1. VCT and MTCT Knowledge and Practice among Men by District, LQAS Survey, Uganda, 2003. Men who know 2+ VCT Men who took an HIV Men who know benefits test about MTCT District % Confidence % Confidence % Confidence interval interval interval Arua 37.7 7.3 8.8 4.5 82.8 5.8 Bushenyi 58.3 9.2 7.4 6.5 63.9 8.1 Iganga 42.2 10.0 6.9 5.0 67.2 9.6 Kabale 64.1 9.9 4.7 5.0 84.4 7.8 Kampala 55.3 9.2 29.9 8.4 92.9 5.2 Kamuli 27.9 8.9 12.2 6.7 73.4 8.1 Kamwenge 44.1 10.2 2.1 4.6 82.6 7.0 Kayunga 43.0 9.8 10.3 6.6 76.1 8.5 Kyenjojo 35.9 8.7 6.9 4.5 82.7 7.8 Lira 22.2 7.6 13.6 6.7 77.2 6.7 Masaka 49.2 9.2 25.3 7.7 89.0 5.9 Masindi 28.1 10.0 4.8 6.5 66.3 8.3 Mayuge 39.2 10.0 21.8 8.2 61.9 9.9 Mbale 61.3 10.0 14.0 6.5 87.0 7.6 Mbarara 58.7 7.6 7.3 5.3 74.7 6.2 Mukono 49.4 9.2 18.3 6.9 81.5 7.5 Rakai 46.6 10.1 26.4 8.8 90.0 5.0 Sironko 45.4 10.0 9.6 5.3 69.4 8.7 Wakiso 52.6 10.0 17.7 8.2 85.1 8.2 Total 46.8 2.1 14.2 1.5 79.6 1.7
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Table A2. Knowledge of MTCT Transmission Routes and Risk Reduction among Men by District, LQAS Survey, Uganda, 2003.
District Knows all 3 routes Knows that the of MTCT MTCT risk can be reduced % C.I. % C.I. Arua 6.2 3.7 65.6 7.2 Bushenyi 6.3 5.0 61.9 8.6 Iganga 5.9 5.0 57.1 10.1 Kabale 14.8 7.0 67.1 9.8 Kampala 8.9 5.5 88.8 6.5 Kamuli 0.5 1.8 62.2 9.0 Kamwenge 6.0 4.9 74.9 8.6 Kayunga 1.5 3.0 69.8 9.3 Kyenjojo 6.5 3.8 77.7 8.4 Lira 0.1 1.5 45.0 8.5 Masaka 2.2 3.8 82.4 7.3 Masindi 7.8 6.3 49.7 10.3 Mayuge 0.5 2.1 51.4 10.1 Mbale 5.0 5.6 72.0 9.5 Mbarara 12.0 5.0 69.1 6.8 Mukono 7.7 4.8 71.8 8.5 Rakai 4.8 4.6 85.6 6.8 Sironko 2.4 5.9 63.7 9.4 Wakiso 4.6 3.5 83.5 8.6 Total 5.9 1.1 69.9 2.0
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Table A3. Percentage of Men Reporting Knowledge of Abstinence, Be Faithful and Condom Use as Strategies of HIV Prevention, LQAS Survey, Uganda, 2003.
District Knows Abstinence Know Be Faithful Know Condom Use % Confidence % Confidence % Confidence interval interval interval Arua 34.4 7.3 59.4 7.4 64.9 7.1 Bushenyi 42.7 8.8 53.0 9.2 71.7 9.0 Iganga 31.1 9.6 56.9 10.1 74.1 8.9 Kabale 83.0 7.9 63.1 10.0 66.8 9.8 Kampala 49.3 9.2 42.5 9.1 87.8 6.3 Kamuli 38.0 9.0 35.8 9.2 72.0 8.5 Kamwenge 69.8 8.9 70.0 9.9 57.4 9.7 Kayunga 29.3 9.5 43.6 10.2 77.6 8.8 Kyenjojo 41.1 9.2 58.8 9.2 72.2 8.5 Lira 21.5 8.0 84.2 7.4 45.8 8.7 Masaka 34.5 9.1 61.4 9.2 73.9 7.4 Masindi 32.0 10.0 54.0 10.2 73.6 7.9 Mayuge 32.4 9.3 58.6 10.0 74.5 9.0 Mbale 43.6 10.1 57.2 9.5 64.4 9.4 Mbarara 77.0 7.0 61.9 7.5 74.0 6.9 Mukono 42.0 9.2 44.3 9.0 85.2 6.5 Rakai 49.9 10.1 59.0 10.1 81.8 8.1 Sironko 32.3 9.6 68.3 9.3 68.9 9.3 Wakiso 49.5 10.0 46.0 10.0 87.5 7.5 Total 44.9 2.1 56.0 2.1 73.7 1.9
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Table A4. Men’s Knowledge of ABC and STI Symptoms by District, LQAS Survey, Uganda, 2003. District Knows 2 + of Knows 2 + STI Knows 2 + STI Abstinence, Be faithful, symptoms in men symptoms in women Condom use % Confidence % Confidence % Confidence interval interval interval Arua 52.1 7.5 40.4 7.4 32.3 7.1 Bushenyi 61.6 9.0 56.6 9.2 48.0 9.0 Iganga 58.2 10.1 62.0 9.9 57.1 10.0 Kabale 82.1 8.2 64.3 9.8 59.8 10.1 Kampala 70.6 8.5 50.1 9.2 35.2 8.6 Kamuli 50.2 9.3 35.3 9.1 31.5 8.6 Kamwenge 78.3 8.8 64.8 9.4 45.7 10.4 Kayunga 51.5 10.3 39.2 10.0 22.5 8.6 Kyenjojo 62.8 9.2 50.9 9.3 34.7 8.7 Lira 46.4 8.6 53.1 8.6 40.9 8.5 Masaka 58.6 9.0 57.4 9.1 29.5 8.6 Masindi 52.6 9.9 50.2 10.1 41.4 10.2 Mayuge 60.6 10.0 40.2 10.0 42.4 10.1 Mbale 66.5 9.4 70.7 9.4 57.5 10.1 Mbarara 88.0 6.3 54.6 7.3 43.6 7.5 Mukono 59.2 9.2 57.2 9.2 48.2 9.2 Rakai 71.3 9.5 54.4 10.2 52.6 10.2 Sironko 67.6 9.6 57.5 10.1 62.6 10.1 Wakiso 74.0 9.6 31.1 9.3 33.1 9.1 Total 64.5 2.1 51.6 2.1 42.2 2.1
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Table A5. Prevalence of Urethritis and Urethral Discharge among Men in the Twelve Months Preceding the Survey and Their Treatment Patterns by District, LQAS Survey, Uganda, 2003. District Reporting urethritis Reporting urethral discharge % Confidence % Confidence interval interval Arua 10.7 5.4 2.3 2.8 Bushenyi 18.9 6.1 12.0 6.1 Iganga 17.4 8.0 1.6 2.3 Kabale 7.8 5.1 2.7 3.1 Kampala 9.9 5.8 4.6 4.5 Kamuli 22.7 8.8 11.3 6.8 Kamwenge 17.4 6.7 11.7 5.8 Kayunga 25.9 9.3 14.4 8.1 Kyenjojo 26.1 9.8 15.4 8.5 Lira 23.8 7.7 10.3 6.6 Masaka 19.3 7.9 8.1 5.9 Masindi 22.7 8.8 4.4 6.6 Mayuge 23.2 8.9 11.3 6.3 Mbale 34.9 9.1 26.6 8.4 Mbarara 13.4 6.0 6.4 4.3 Mukono 25.1 8.3 14.4 6.4 Rakai 25.3 9.9 13.3 8.1 Sironko 24.1 8.8 12.0 7.3 Wakiso 11.7 7.0 0.7 3.9 Total 18.8 1.8 8.9 1.4
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Table A6. Treatment Type for Those Who Sought Treatment by District, LQAS Survey, Uganda, 2003. District Type of facility Government Private Traditional Pharmacy Self- Other health health healer medication facility facility Arua 46.5 26.3 0.0 4.9 17.4 4.9 Bushenyi 61.7 37.5 0.0 0.0 0.0 0.7 Iganga 42.9 35.9 0.0 21.2 0.0 0.0 Kabale 60.0 40.0 0.0 0.0 0.0 0.0 Kampala 33.5 51.2 15.3 0.0 0.0 0.0 Kamuli 37.2 25.8 10.7 0.0 22.2 4.1 Kamwenge 47.7 52.3 0.0 0.0 0.0 0.0 Kayunga 44.9 49.3 0.0 0.0 5.8 0.0 Kyenjojo 25.7 58.5 1.4 10.9 3.5 0.0 Lira 47.6 51.7 0.0 0.7 0.0 0.0 Masaka 41.1 41.7 0.0 9.4 7.7 0.0 Masindi 55.6 15.5 28.8 0.0 0.0 0.0 Mayuge 45.1 27.1 3.8 11.9 0.0 11.9 Mbale 42.9 26.8 2.3 17.1 8.5 2.3 Mbarara 49.1 50.3 0.0 0.0 0.6 0.0 Mukono 26.2 26.4 7.6 6.3 33.5 0.0 Rakai 44.6 43.6 0.0 0.0 5.8 6.1 Sironko 57.5 22.5 2.4 17.6 0.0 0.0 Wakiso 4.8 26.8 0.0 4.8 63.6 1.4 Total 41.7 37.2 3.8 6.2 9.7 1.4
Note: As the Ns were small for each of these calculations the confidence intervals are very wide.
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Table A7. Men’s Attitudes towards Common Misconceptions, Risk Perception, Sexual Practices and Condom Use by District on HIV Transmission, LQAS Survey, Uganda, 2003. District Reject all Perceived high Perceived low Ever used Sex with non- Used condom misconceptions risk risk condom regular partner with non- regular partner % C.I. % C.I. % C.I. % C.I. % C.I. % C.I. Arua 46.5 7.5 7.9 4.2 70.5 6.9 39.0 7.4 12.3 5.4 40.5 23.1 Bushenyi 37.8 8.8 33.1 8.1 52.4 9.0 40.7 8.7 22.3 7.0 43.2 23.8 Iganga 44.7 10.1 48.6 10.2 49.2 10.2 48.1 10.1 24.4 8.8 28.4 19.1 Kabale 53.6 10.3 19.7 8.3 69.0 9.3 17.7 8.0 11.0 6.7 32.3 29.8 Kampala 58.1 9.1 24.8 7.9 72.2 8.3 78.9 7.6 29.7 8.6 74.0 14.7 Kamuli 49.1 9.3 60.3 9.2 32.9 9.0 43.5 9.2 23.4 8.4 56.2 23.2 Kamwenge 50.4 10.1 16.2 8.5 73.5 9.9 22.0 9.4 21.8 8.0 23.5 23.4 Kayunga 45.9 10.3 33.9 9.5 61.1 9.9 62.5 10.5 40.2 11.0 46.5 17.6 Kyenjojo 54.0 9.3 33.9 8.8 58.6 9.3 35.6 8.9 23.4 8.8 21.5 16.1 Lira 44.9 8.3 37.0 7.8 60.1 8.3 23.2 7.9 13.6 6.4 14.5 19.1 Masaka 54.5 9.2 38.9 9.1 59.9 9.2 50.2 8.8 22.5 8.5 18.7 17.1 Masindi 49.3 10.14 28.2 8.5 61.1 9.6 42.3 10.0 16.3 8.7 21.9 19.9 Mayuge 50.7 10.0 43.1 9.9 44.5 10.1 49.7 10.1 29.5 8.9 51.8 21.3 Mbale 46.8 10.2 30.6 9.6 57.3 10.9 46.2 10.2 29.1 9.9 35.3 17.6 Mbarara 61.6 7.5 17.2 6.5 72.9 7.0 50.5 7.4 16.8 6.0 34.7 18.2 Mukono 50.0 9.4 48.9 9.3 46.5 9.2 72.5 8.6 39.9 9.3 51.0 16.1 Rakai 62.5 10.0 43.5 10.1 50.2 10.2 58.0 10.1 30.9 9.6 32.0 16.6 Sironko 29.7 9.9 18.3 8.8 63.8 9.7 45.6 10.1 17.6 8.3 8.5 18.8 Wakiso 58.5 10.1 36.5 9.6 55.6 9.8 76.8 94 28.1 9.3 48.9 18.2 Total 51.1 2.1 32.5 2.0 59.0 2.1 50.9 2.1 23.7 1.9 42.0 4.5
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Appendix B. Key Women’s Indicators by District
Table B1. VCT and MTCT Knowledge and Practice among Women by District, LQAS Survey, Uganda, 2003. District Women who know 2+ Women who took an HIV Women who know about VCT benefits test MTCT % Confidence % Confidence % Confidence interval interval interval Arua 18.3 5.9 8.2 4.8 65.3 7.1 Bushenyi 49.2 9.2 10.2 5.2 84.2 6.8 Iganga 38.9 9.7 2.4 2.9 68.8 9.5 Kabale 53.7 10.3 5.4 5.5 67.9 9.4 Kampala 53.0 9.2 37.5 8.9 96.3 4.1 Kamuli 24.7 7.9 6.8 4.7 67.2 8.7 Kamwenge 40.3 10.0 7.5 3.5 67.0 8.1 Kayunga 32.0 9.4 6.9 5.6 63.1 9.8 Kyenjojo 28.6 8.3 5.6 4.8 79.1 8.0 Lira 18.0 6.2 7.8 4.7 81.8 6.3 Masaka 54.1 9.2 20.1 7.2 94.2 4.4 Masindi 32.5 10.0 6.6 5.7 73.8 9.2 Mayuge 16.8 6.8 9.9 6.0 59.4 10.1 Mbale 45.5 10.0 8.0 5.6 80.9 8.2 Mbarara 52.9 7.5 2.3 4.7 61.2 6.3 Mukono 37.8 8.8 23.2 7.3 84.5 6.4 Rakai 40.9 10.0 24.7 8.9 91.9 5.7 Sironko 40.1 9.5 6.0 5.3 75.8 8.3 Wakiso 33.6 9.8 27.1 9.1 87.8 7.2 Total 38.8 2.1 13.8 1.4 78.1 1.8
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Table B2. Knowledge of MTCT Transmission Routes and Risk Reduction among Women by District, LQAS Survey, Uganda, 2003. District Knows transmission route Know that the Know all 3 Pregnancy Delivery Breast- MTCT risk can routes of MTCT feeding be reduced % C.I. % C.I. % C.I. % C.I. % C.I. Arua 65.9 8.9 42.6 9.2 47.5 9.3 8.5 4.4 30.1 7.2 Bushenyi 39.9 10.6 74.0 9.5 55.5 10.6 13.9 5.2 51.7 9.2 Iganga 56. 12.2 80.3 9.9 49.8 12.4 15.5 7.2 38.9 9.8 Kabale 55.9 12.3 90.2 7.6 34.1 11.9 11.7 6.9 52.5 10.2 Kampala 40.0 9.3 84.4 7.1 52.8 9.5 13.6 6.6 79.4 7.8 Kamuli 49.4 11.3 50.6 11.3 12.4 8.5 1.9 2.4 32.4 8.8 Kamwenge 40.6 11.3 65.3 10.6 36.0 11.1 4.3 1.6 42.0 10.0 Kayunga 36.8 12.4 68.8 12.9 16.8 10.0 1.4 2.9 45.5 10.0 Kyenjojo 51.0 10.7 76.1 10.1 24.2 9.1 8.5 4.8 60.3 9.2 Lira 41.1 9.3 56.2 9.2 18.8 7.3 0.2 2.1 43.0 8.4 Masaka 54.8 9.5 70.0 7.8 36.1 9.3 11.3 5.9 76.6 7.3 Masindi 34.1 9.7 65.7 11.1 20.6 10.8 1.8 4.1 36.8 10.0 Mayuge 48.2 13.3 57.4 13.2 18.2 9.9 2.3 3 30.9 9.4 Mbale 73.2 10.4 33.5 11.3 27.8 10.5 10.1 6.2 30.9 9.8 Mbarara 67.0 8.8 80.1 7.3 40.9 8.8 16.0 9.3 49.1 7.5 Mukono 47.7 9.9 65.3 9.5 35.3 9.3 7.4 4.7 50.2 9.3 Rakai 51.7 10.6 98.2 6.8 41.8 10.5 19.7 7.9 71.8 9.1 Sironko 54.0 11.2 39.6 11.5 46.1 11.4 9.9 6.0 47.3 10.1 Wakiso 29.0 10.0 86.0 8.4 35.0 10.6 4.8 4.1 72.6 9.4 Total 49.0 2.5 69.1 2.3 36.8 2.4 9.3 1.2 51.7 2.2
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Table B3. Percentage of Women Reporting Knowledge of Abstinence, Be Faithful and Condom Use as Strategies of HIV Prevention, LQAS Survey, Uganda, 2003. District Know Abstinence Know Be Faithful Know Condom Use % Confidence % Confidence % Confidence interval interval interval Arua 29.3 6.9 53.1 7.6 24.4 6.8 Bushenyi 59.2 8.8 41.0 9.9 71.9 9.4 Iganga 31.7 9.5 49.4 10.1 61.9 9.9 Kabale 85.5 8.1 47.8 10.2 55.7 10.2 Kampala 41.7 9.1 41.5 9.0 85.2 6.9 Kamuli 28.1 8.4 31.3 8,2 54.3 9.2 Kamwenge 66.8 9.1 56.4 8.1 40.8 10.1 Kayunga 34.0 9.1 35.0 9.7 69.7 9.6 Kyenjojo 39.0 9.3 55.3 9.3 56.1 9.3 Lira 24.4 7.2 57.5 7.9 38.0 8.4 Masaka 41.0 9.2 41.2 8.9 78.7 7.6 Masindi 26.8 9.6 59.0 10.1 65.0 8.8 Mayuge 34.2 9.7 48.0 10.2 55.1 10.2 Mbale 41.0 9.9 62.1 9.9 53.8 9.9 Mbarara 82.6 6.6 43.4 7.6 53.8 7.5 Mukono 43.1 9.2 27.8 8.4 70.9 8.4 Rakai 36.1 9.6 57.0 10.1 65.7 9.5 Sironko 21.9 8.5 62.5 9.7 71.4 9.8 Wakiso 45.3 10.1 29.9 9.8 80.7 8.8 Total 43.9 2.1 45.4 2.2 61.9 2.1
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Table B4. Women’s Knowledge of ABC and STI Symptoms by District, LQAS Survey, Uganda, 2003. District Knows 2 + of Abstinence, Knows 2 + STI symptoms Knows 2 + STI symptoms Be faithful, Condom use in men in women % Confidence % Confidence % Confidence interval interval interval Arua 27.8 7.0 16.4 5.7 26.1 6.7 Bushenyi 69.6 9.1 38.3 8.8 64.5 9.2 Iganga 46.5 10.1 40.3 10.0 58.0 10.0 Kabale 72.1 9.8 50.1 10.2 54.0 10.1 Kampala 62.9 9.1 27.6 8.2 61.3 9.9 Kamuli 27.0 8.3 16.9 6.9 43.3 9.1 Kamwenge 58.9 9.9 14.2 6.9 63.8 9.8 Kayunga 38.2 9.6 20.2 8.2 41.6 10.0 Kyenjojo 48.8 9.3 30.9 7.0 43.2 9.1 Lira 28.5 8.2 29.0 7.9 41.2 8.4 Masaka 55.4 9.1 26.4 8.0 44.6 9.2 Masindi 48.3 10.0 31.4 9.5 61.6 9.5 Mayuge 39.9 10.0 28.1 9.2 48.6 10.1 Mbale 49.1 10.1 45.4 10.0 62.1 9.8 Mbarara 59.3 7.3 41.1 7.3 56.8 7.5 Mukono 49.3 9.2 44.1 8.9 68.3 8.8 Rakai 51.8 10.1 44.8 10.0 67.8 9.4 Sironko 56.6 10.1 42.4 10.1 64.2 9.6 Wakiso 49.1 10.2 22.6 7.6 41.6 10.2 Total 49.7 2.2 32.9 2.0 52.9 2.1
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Table B5. Women’s Attitudes towards Common Misconceptions, Risk Perception, Sexual Practices and Condom Use by District on HIV Transmission, LQAS Survey, Uganda, 2003. District Reject all Perceived Perceived Ever used Sex with Used misconceptions high risk low risk condom non-regular condom partner with non- regular partner % C.I. % C.I. % C.I. % C.I. % C.I. % C.I. Arua 41.2 9.5 7.7 4.5 60.6 7.4 12.6 5.3 2.2 2.4 0.0 N/A Bushenyi 25.6 9.0 33.5 8.3 49.4 9.3 28.1 7.3 9.6 4.2 5.1 3.5 Iganga 46.4 10.1 42.6 10.9 48.1 10.1 21.8 8.1 8.9 5.7 2.5 2.9 Kabale 42.3 10.1 37.1 9.8 50.0 10.2 16.2 7.5 6.4 5.0 1.7 2.3 Kampala 56.6 9.2 35.8 8.8 55.1 9.1 59.2 9.1 12.4 6.0 6.1 4.5 Kamuli 28.2 8.3 60.7 9.2 27.7 8.5 27.1 8.2 6.7 4.8 3.2 3.4 Kamwenge 36.8 9.7 16.4 8.6 69.8 10.2 8.8 7.4 2.3 5.0 4.9 5.0 Kayunga 39.2 9.9 36.8 9.8 49.6 10.1 28.3 8.9 19.7 7.6 10.8 5.8 Kyenjojo 60.4 9.3 34.7 8.9 52.9 9.2 24.5 8.3 6.2 5.0 1.1 2.8 Lira 20.0 7.4 35.7 8.3 56.4 8.5 12.4 5.6 2.5 3.3 0.0 N/A Masaka 39.0 8.8 53.3 9.2 44.0 9.1 30.7 9.1 6.2 4.8 2.4 4.2 Masindi 36.2 9.6 24.1 9.0 54.4 10.0 32.0 9.9 13.3 5.6 4.7 3.7 Mayuge 31.5 9.5 43.8 10.1 37.5 9.8 21.3 8.0 8.4 5.8 2.1 2.3 Mbale 43.0 10.0 25.8 9.2 60.8 10.1 25.3 9.2 9.6 6.8 1.2 3.2 Mbarara 51.0 7.5 27.2 6.9 70.8 7.4 25.0 5.9 5.6 3.2 0.3 1.7 Mukono 43.6 9.2 58.5 9.2 27.7 8.4 39.4 9.0 16.6 6.8 4.3 4.1 Rakai 44.6 10.0 42.5 10.0 52.1 10.1 38.2 9.7 9.3 6.1 4.1 3.7 Sironko 33.4 9.8 22.6 9.8 49.0 10.0 20.0 7.5 2.4 5.5 0.5 2.2 Wakiso 41.9 10.1 32.7 9.6 56.5 10.2 66.8 10.1 12.9 7.7 11.1 6.7 Total 41.2 2.1 35.9 2.1 51.8 2.1 31.4 1.9 8.6 1.2 3.5 0.8
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Appendix C. Key Mothers’ Indicators by District
Table C1. Mothers’ Knowledge about the Risk of Mother-To-Child Transmission of HIV by District, LQAS Survey, Uganda, 2003. Percentage knowing Percentage knowing risk MTCT exists can be reduced District Confidence Confidence % % Interval Interval Arua 75.5 6.5 42.4 7.5 Bushenyi 82.7 6.4 65.7 8.8 Iganga 80.5 8.1 30.0 9.1 Kabale 80.3 8.7 51.2 10.1 Kampala 96.2 3.4 78.4 7.4 Kamuli 63.0 8.7 32.9 8.9 Kamwenge 86.5 6.0 64.9 10.2 Kayunga 62.4 9.8 46.8 10.0 Kyenjojo 74.7 7.8 51.7 9.3 Lira 83.8 6.6 33.6 8.2 Masaka 93.4 5.0 70.9 8.6 Masindi 69.7 9.4 41.4 10.1 Mayuge 60.1 10.0 35.2 9.4 Mbale 56.9 9.8 16.8 8.8 Mbarara 88.4 5.7 52.8 7.5 Mukono 83.1 7.3 49.1 9.2 Rakai 89.1 6.5 62.7 9.8 Sironko 63.3 9.6 31.6 9.6 Wakiso 94.1 5.6 78.6 8.7 Total 80.8 1.8 51.6 2.1
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Table C2. Mothers’ Use of Antenatal Care Services by District, LQAS Survey, Uganda, 2003. Attended Showed No. of visits District ANC card 1 2 3 4+ % C.I. % C.I. Arua 93.1 3.8 42.1 27.4 11.9 29.7 23.8 34.5 Bushenyi 90.2 5.0 26.9 31.4 1.5 3.7 49.8 45.1 Iganga 90.0 6.5 19.5 37.2 15.2 34.2 29.4 21.3 Kabale 88.3 7.0 33.7 41.2 14.6 21.2 21.7 42.5 Kampala 98.2 2.4 19.2 25.5 11.1 22.8 8.4 57.7 Kamuli 93.9 4.7 27.8 33.3 34.3 23.0 21.6 21.0 Kamwenge 87.7 5.7 34.5 37.2 28.2 16.9 35.2 19.7 Kayunga 88.1 6.9 16.8 39.2 9.3 47.8 35.6 7.2 Kyenjojo 84.4 6.9 25.9 39.2 23.8 18.1 22.3 35.8 Lira 98.5 3.3 26.7 27.4 19.8 19.6 21.8 38.8 Masaka 90.9 4.7 27.8 31.4 19.5 51.0 14.7 14.9 Masindi 93.4 5.3 30.4 37.2 19.6 24.1 31.2 25.1 Mayuge 94.6 5.7 33.4 37.2 13.4 23.5 41.1 22.0 Mbale 85.8 6.5 30.3 39.2 29.3 21.5 20.6 28.6 Mbarara 87.9 5.7 17.0 31.4 24.3 22.3 3.9 49.5 Mukono 93.5 5.0 26.3 33.3 23.1 25.8 9.2 41.9 Rakai 87.4 6.5 15.5 35.3 14.6 53.8 3.0 28.7 Sironko 94.0 5.6 18.8 35.3 25.5 34.3 10.1 30.1 Wakiso 95.7 3.5 25.7 29.4 1.5 9.3 12.2 77.0 Total 92.0 1.2 25.9 7.8 17.6 24.7 20.9 36.8
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Table C3. Women’s Delivery Practices by District, LQAS Survey, Uganda, 2003. Delivered Place of birth: Delivered in Delivery under Clinic health Own Other’s Health practice trained Hospital (public/ Other facility home home centre provider private) % C.I. % C.I. % % % % % % Arua 22.7 6.6 25.6 6.8 73.4 3.3 9.0 11.7 2.1 0.5 Bushenyi 48.8 9.1 50.8 9.1 46.3 4.9 17.3 16.7 14.8 0.0 Iganga 60.1 9.9 65.1 9.6 28.9 5.5 7.7 30.2 22.2 5.5 Kabale 34.0 9.8 33.1 9.7 62.6 3.0 17.4 15.2 1.4 0.5 Kampala 94.7 4.1 94.7 4.1 3.8 1.5 66.2 11.3 17.2 0.0 Kamuli 69.2 8.5 69.7 8.4 24.1 6.2 13.4 30.0 25.7 0.6 Kamwenge 12.8 7.2 13.1 7.6 76.7 7.0 5.6 6.3 0.9 3.5 Kayunga 47.1 10.1 48.2 10.1 38.2 14.8 14.0 21.0 12.0 0.0 Kyenjojo 28.8 8.6 28.5 8.5 62.9 5.2 10.3 13.7 4.7 3.1 Lira 35.3 8.4 41.7 8.4 61.4 3.4 10.5 23.3 1.4 0.0 Masaka 50.2 9.1 54.5 8.9 20.8 28.5 11.6 4.0 34.6 0.5 Masindi 24.2 9.8 24.5 9.8 66.4 8.8 14.5 7.9 1.8 0.5 Mayuge 54.4 10.2 55.7 10.2 42.4 2.6 9.5 23.5 21.5 0.6 Mbale 37.8 10.0 36.1 10.0 56.1 6.1 14.0 11.5 12.2 0.0 Mbarara 24.2 7.3 30.4 7.5 75.0 0.6 12.8 10.2 1.2 0.2 Mukono 72.0 8.6 70.6 8.6 19.0 6.7 25.4 17.6 29.0 2.3 Rakai 45.1 10.1 44.4 10.1 22.1 32.9 20.2 16.0 8.9 0.0 Sironko 25.3 9.6 33.9 9.8 64.8 5.8 9.9 14.3 1.0 4.1 Wakiso 92.0 6.8 87.6 7.2 2.7 1.3 36.3 22.1 33.6 4.0 Total 51.2 2.1 52.8 2.1 40.7 6.9 20.5 16.0 14.6 1.2
Note: The district Ns for place of birth were too small to calculate meaningful confidence intervals.
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Table C4. Counseling and Testing Patterns among Pregnant Women by District, LQAS Survey, Uganda, 2003. District Counseled about Counseled to take Took HIV test PMTCT HIV test % Conf. % Conf. % Conf. Interval Interval Interval Arua 57.5 10.5 42.1 7.7 14.8 6.0 Bushenyi 51.3 9.6 52.1 9.7 16.9 7.0 Iganga 25.4 9.6 18.1 8.2 1.9 3.3 Kabale 58.6 10.6 51.8 10.8 3.1 4.1 Kampala 70.6 8.6 66.4 8.7 47.8 9.3 Kamuli 30.1 12.0 27.0 8.4 10.8 5.4 Kamwenge 34.3 9.9 46.5 10.1 8.6 5.5 Kayunga 30.0 18.1 27.2 9.0 0.0 0.0 Kyenjojo 31.7 13.3 39.8 10.0 8.3 6.2 Lira 32.6 7.9 22.6 7.4 1.2 3.7 Masaka 25.6 8.8 28.3 9.1 5.0 6.1 Masindi 29.7 9.8 32.1 10.2 4.9 7.0 Mayuge 27.0 9.1 17.6 7.4 4.8 4.0 Mbale 35.0 10.6 21.0 9.0 4.3 5.1 Mbarara 52.2 8.3 43.5 8.2 2.2 5.3 Mukono 40.0 12.5 27.2 8.2 5.4 4.1 Rakai 39.4 10.5 32.6 9.9 5.2 4.7 Sironko 19.1 9.5 25.0 10.0 1.8 5.0 Wakiso 57.9 10.1 51.3 9.7 32.7 10.2 Total 43.8 2.4 37.9 2.2 12.8 1.5
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Appendix D. Key Young People District Indicators
Table D1. Young People’s Knowledge of ABC, Their Attitudes towards Common HIV Misconceptions, and Their Risk Perception by District, LQAS Survey, Uganda, 2003. District Know at least Reject all Perceived Perceived 2 of the ABC misconceptions high risk low risk % C.I. % C.I. % C.I. % C.I. Arua 30.0 7.0 43.1 7.5 10.4 4.6 67.4 7.1 Bushenyi 53.0 9.3 31.4 9.1 36.5 8.9 56.7 9.3 Iganga 56.0 10.1 41.4 9.9 38.1 9.9 56.5 10.1 Kabale 64.6 10.0 45.9 10.3 34.2 9.7 46.9 10.3 Kampala 61.2 9.2 58.8 9.2 19.4 7.1 71.1 8.2 Kamuli 44.3 9.2 45.3 9.1 56.9 9.2 41.3 9.2 Kamwen 65.7 9.7 26.7 9.6 20.3 8.7 63.5 10.3 ge Kayunga 48.8 10.4 48.2 10.1 38.4 10.1 43.4 10.3 Kyenjojo 52.7 9.3 51.6 9.3 40.2 9.0 50.3 9.3 Lira 46.0 8.6 29.7 7.8 37.1 8.3 58.4 8.5 Masaka 50.0 9.3 27.1 8.7 36.9 9.2 58.4 9.3 Masindi 48.0 10.3 51.7 10.3 28.2 9.2 62.0 9.9 Mayuge 49.0 10.1 41.0 9.8 38.8 9.6 46.7 10.1 Mbale 61.6 9.7 55.3 10.2 25.6 9.3 60.4 10.1 Mbarara 72.9 7.2 60.7 7.6 26.5 6.7 67.0 7.5 Mukono 43.6 9.3 40.3 9.2 45.5 9.3 40.8 9.1 Rakai 55.7 10.1 47.8 10.1 34.9 9.8 54.6 10.2 Sironko 63.2 9.9 35.1 9.6 19.6 9.4 58.0 10.1 Wakiso 37.7 10.1 44.9 10.1 39.9 9.8 51.1 10.1 Total 52.4 2.2 44.8 2.1 32.6 2.0 57.0 2.1
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Table D2. Percentage of Young People Reporting Knowledge of Abstinence, Be Faithful and Condom Use as Strategies of HIV Prevention, LQAS Survey, Uganda, 2003. District Know Abstinence Know Be Faithful Know Condom Use % Confidence % Confidence % Confidence interval interval interval Arua 30.9 7.0 32.4 6.9 50.3 7.5 Bushenyi 74.0 8.5 23.0 6.6 59.8 9.2 Iganga 39.7 10.0 38.0 9.8 83.0 7.8 Kabale 88.3 7.4 28.1 9.3 62.4 10.0 Kampala 57.0 9.3 16.8 7.3 90.9 5.8 Kamuli 36.5 9.1 21.2 7.5 80.6 7.5 Kamwenge 81.2 8.3 39.9 9.9 56.1 9.7 Kayunga 46.8 10.4 24.8 8.8 81.0 9.1 Kyenjojo 47.9 9.3 38.7 9.0 68.1 8.9 Lira 41.2 8.5 42.7 8.5 63.2 8.2 Masaka 39.9 9.3 36.4 8.5 81.9 7.4 Masindi 37.5 10.2 32.9 9.7 82.2 6.5 Mayuge 38.5 9.9 30.9 9.2 78.9 8.6 Mbale 62.0 10.1 33.5 9.8 71.0 8.6 Mbarara 78.3 6.5 27.1 7.0 83.2 6.6 Mukono 53.3 9.4 10.9 6.4 79.0 7.5 Rakai 45.5 10.2 37.8 9.9 75.9 8.6 Sironko 47.5 10.1 46.6 10.1 74.2 9.1 Wakiso 44.5 10.1 15.0 8.2 27.6 8.6 Total 52.3 2.2 28.2 2.0 74.8 1.9
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Table D3. Sexual Behaviour and Condom Use among Young People by District, LQAS Survey, Uganda, 2003. District Condom use Sex with Used Always uses Know at least during first non-regular condom with condom 3 correct steps sex partner in non-regular of condom past 12 partner use months % C.I. % C.I. % C.I. % C.I. % C.I. Arua 25.6 8.8 17.2 8.7 48.1 26.1 9.6 6.0 17.1 6.0 Bushenyi 17.6 9.7 33.0 11.5 29.9 21.9 13.1 9.9 32.9 8.2 Iganga 49.9 13.1 21.5 11.7 46.5 27.2 26.2 11.3 31.8 9.6 Kabale 19.0 11.6 38.1 14.4 32.1 26.1 10.2 8.4 23.2 8.9 Kampala 58.4 10.9 32.4 10.3 86.4 13.0 49.9 11.1 34.7 8.9 Kamuli 24.7 9.5 45.8 10.2 58.0 23.2 17.1 8.7 17.8 7.5 Kamwenge 32.8 11.7 28.1 11.8 5.6 23.3 15.8 10.8 12.3 8.6 Kayunga 40.4 12.6 30.0 12.0 84.0 22.3 24.3 10.2 25.7 8.9 Kyenjojo 22.3 10.8 18.8 10.4 66.0 27.6 11.0 8.3 11.0 6.6 Lira 19.6 9.2 36.8 10.3 26.8 20.2 13.9 6.6 33.5 8.1 Masaka 35.3 11.5 16.6 9.5 87.0 23.2 25.0 10.5 28.2 8.5 Masindi 32.7 11.6 13.6 10.2 84.8 21.2 10.3 8.9 37.8 10.3 Mayuge 37.8 12.3 16.0 10.0 63.4 34.4 27.2 11.6 34.4 10.2 Mbale 25.8 11.4 39.2 12.8 52.0 20.0 25.7 10.9 43.6 10.3 Mbarara 35.3 9.7 34.5 9.6 25.9 21.9 26.7 8.7 31.6 6.8 Mukono 42.5 11.2 35.8 11.8 36.9 20.2 24.2 8.9 32.4 8.9 Rakai 40.4 11.5 42.1 11.6 64.4 19.1 21.3 9.4 42.4 10.1 Sironko 48.4 10.1 31.1 11.3 34.7 22.3 31.6 8.5 28.3 9.6 Wakiso 43.2 11.7 44.0 11.5 79.9 17.0 47.9 11.5 34.5 9.6 Total 35.7 2.6 30.2 2.5 55.7 5.2 25.5 2.2 30.2 2.0
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Table D4.Knowledge of STI Symptoms and MTCT Risk among Young People, LQAS Survey, Uganda, 2003. District Know 2+ STI Know 2+ STI Know MTCT symptoms in symptoms in risk can be men women reduced % C.I. % C.I. % C.I. Arua 15.6 5.4 19.8 6.0 27.9 6.9 Bushenyi 36.0 7.6 34.3 8.1 46.4 9.3 Iganga 44.5 10.0 48.9 10.1 48.0 10.1 Kabale 48.6 10.2 52.3 10.3 59.2 10.2 Kampala 24.1 7.5 34.8 8.8 68.2 8.7 Kamuli 22.4 7.6 22.4 7.2 49.1 9.2 Kamwenge 18.2 9.3 28.3 9.3 49.3 10.1 Kayunga 20.9 7.5 19.7 7.7 57.1 10.3 Kyenjojo 28.1 8.3 32.9 8.2 55.4 9.2 Lira 34.5 8.0 34.8 8.2 49.8 8.6 Masaka 12.4 6.3 20.0 7.8 67.1 8.6 Masindi 30.5 9.9 33.2 10.2 35.8 10.7 Mayuge 14.8 8.0 33.7 9.6 33.6 9.8 Mbale 31.4 9.6 32.3 9.6 54.3 10.3 Mbarara 23/1 7.1 45.3 7.2 75.2 7.6 Mukono 19.8 6.7 27.1 7.9 55.7 9.3 Rakai 26.9 9.3 39.6 10.1 71.0 9.1 Sironko 23.6 9.6 20.3 9.6 34.3 9.9 Wakiso 18.7 7.2 24.2 8.5 77.6 8.7 Total 25.7 2.0 32.2 2.0 56.1 2.2
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Appendix E. Key Orphans’ Indicators by District
Table E1. Educational attendance among Orphans by District, LQAS Survey, Uganda, 2003. Attended for Orphans attending School Level attended 5 days in last week District Never One parent No parent Primary Secondary+ attended % C.I. % C.I. % C.I. % % % Arua 83.0 7.1 17.0 13.3 89.6 3.1 7.3 72.2 19.6 Bushenyi 61.5 8.9 38.5 21.1 94.9 4.8 0.3 82.6 23.5 Iganga 79.5 6.8 20.5 17.5 80.5 12.1 1.4 77.5 23.5 Kabale 67.6 10.1 32.4 22.3 90.0 9.6 0.4 82.7 27.4 Kampala 45.0 6.6 55.0 21.1 85.7 12.7 1.6 59.5 43.1 Kamuli 70.1 7.2 29.9 17.9 83.9 11.9 5.2 71.3 33.3 Kamwenge 63.7 8.5 36.3 22.0 84.9 8.0 7.1 72.4 35.3 Kayunga 65.5 8.9 34.5 24.3 82.7 15.5 2.8 80.3 16.9 Kyenjojo 60.4 10.2 39.6 22.6 92.6 1.7 5.7 64.8 35.3 Lira 70.2 7.8 29.8 17.4 95.1 4.3 0.6 48.3 43.1 Masaka 62.4 7.3 37.6 20.0 87.7 7.2 5.1 68.0 31.3 Masindi 77.1 8.8 22.9 19.8 90.7 5.6 3.7 63.3 23.5 Mayuge 69.1 10.2 30.0 21.1 89.2 5.4 5.4 78.3 33.4 Mbale 67.2 10.1 32.8 20.3 79.7 9.6 11.7 70.1 29.4 Mbarara 47.8 5.8 52.2 18.5 97.6 1.6 0.8 70.5 21.6 Mukono 62.6 6.4 37.4 19.1 86.9 8.9 4.2 86.0 18.9 Rakai 54.8 7.0 45.2 22.4 84.5 10.4 5.1 79.0 23.5 Sironko 51.8 6.8 48.2 22.6 88.0 10.1 1.9 73.9 27.4 Wakiso 57.7 6.0 42.3 23.3 73.5 25.4 1.1 71.1 41.2 Total 64.1 4.7 35.9 13.6 87.1 9.2 3.8 71.6 1.7
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Table E2. Patterns of Orphan Support by District, LQAS Survey, Uganda, 2003. Educational Psychosocial Material Food support District support support support % C.I. % C.I. % C.I. % C.I. Arua 15.2 5.6 5.9 3.8 5.7 4.1 3.1 2.7 Bushenyi 29.4 8.6 5.5 6.2 14.0 6.7 .8 3.0 Iganga 37.3 9.6 14.2 6.7 5.3 4.9 13.3 6.5 Kabale 27.4 8.8 30.6 9.2 21.7 8.2 4.6 4.2 Kampala 9.6 5.5 13.4 6.1 1.5 2.2 3.9 3.8 Kamuli 2.7 3.4 5.2 4.7 0.8 1.9 1.6 1.7 Kamwenge 14.5 7.8 2.4 4.1 2.8 6.1 0.0 N/A Kayunga 27.0 8.7 12.9 7.0 13.9 7.5 0.0 N/A Kyenjojo 18.6 7.3 4.8 3.5 4.3 6.2 8.2 4.7 Lira 11.0 6.0 12.3 5.4 6.4 3.6 1.3 2.5 Masaka 9.6 6.2 9.8 5.2 8.5 6.1 2.2 3.8 Masindi 4.0 5.9 1.4 3.7 9.4 3.4 4.5 3.0 Mayuge 12.3 6.5 9.9 5.9 0.8 2.6 0.5 2.1 Mbale 22.9 9.1 8.9 7.0 3.3 4.8 1.3 3.6 Mbarara 6.8 5.1 5.6 3.7 0.8 3.2 0.9 2.9 Mukono 10.5 5.1 16.0 6.0 4.9 3.7 2.4 2.5 Rakai 18.3 8.0 16.5 7.2 10.3 7.0 1.6 2.1 Sironko 8.6 7.9 16.4 7.8 0.3 2.3 7.0 6.5 Wakiso 16.8 6.2 0.9 3.0 1.9 4.7 0.5 2.2 Total 15.4 1.6 9.7 1.3 5.3 1.0 3.0 0.8
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Appendix F. Key PLWHA Indicators by District
Table F1. Sickness and Care Seeking Behaviour among PLWHAs by District, LQAS Survey, Uganda, 2003. District Sick in last 1 Received Psycho-social Income Material month med. Care generating act. support % C.I. % C.I. % C.I. % C.I. % C.I. Arua 70.5 9.2 87.0 4.1 73.7 8.9 37.9 9.8 1.1 2.1 Bushenyi 72.9 8.9 92.9 6.1 83.3 8.5 33.3 9.5 3.1 3.5 Iganga 82.3 7.1 92.1 5.3 87.3 3.0 62.8 9.0 6.2 4.5 Kabale 80.5 8.9 85.5 8.8 59.2 11.1 41.3 11.2 14.5 8.0 Kampala 73.7 8.9 100.0 N/A 76.8 8.5 60.0 9.9 8.4 5.6 Kamuli 89.5 6.9 79.4 9.6 73.7 10.0 46.1 11.3 38.2 11.0 Kamwenge 81.1 7.9 98.7 2.55 52.6 10.1 17.9 7.8 1.1 2.1 Kayunga 76.3 13.7 75.9 15.8 71.1 14.6 52.6 16.1 0.0 0.0 Kyenjojo 63.2 8.9 98.6 4.7 53.1 9.2 50.9 9.2 9.0 5.4 Lira 86.3 6.9 95.1 4.7 75.8 8.7 50.5 10.1 42.6 10.1 Masaka 85.3 7.2 97.5 3.4 89.5 6.2 35.8 9.7 23.2 8.5 Masindi 77.6 9.4 94.9 5.6 61.3 11.1 30.3 10.4 1.3 2.6 Mayuge 86.8 10.9 100.0 N/A 81.6 12.5 52.6 16.1 0.0 N/A Mbale 89.5 6.2 97.6 3.2 90.5 5.9 30.5 9.3 2.1 2.9 Mbarara 78.7 8.3 97.3 3.7 86.2 7.0 53.2 10.1 10.6 6.3 Mukono 88.2 7.3 86.6 8.2 65.8 10.7 38.2 11.0 13.2 7.7 Rakai 80.3 9.0 100.0 N/A 92.0 6.2 41.3 11.2 26.7 10.1 Sironko 53.7 10.1 100.0 N/A 72.6 9.0 12.6 6.7 0.0 N/A Wakiso 84.2 8.3 98.4 3.1 100.0 N/A 21.1 9.2 6.7 5.7 Total 78.3 2.0 94.5 1.3 76.7 2.1 40.3 2.4 11.2 1.5
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Table F2. Food Support Received by PLWHAs in Different Time Periods by District, LQAS Survey, Uganda, 2003. District Food support In last one In last one In last three (any duration) week month months % C.I. % C.I. % C.I. % C.I. Arua 44.2 10.0 3.2 3.5 24.2 8.7 43.2 10.2 Bushenyi 26.0 8.3 7.4 5.7 24.0 8.6 23.0 8.9 Iganga 28.4 8.3 5.6 4.3 22.5 7.8 24.1 8.0 Kabale 6.6 5.6 5.3 5.1 6.7 5.7 6.7 5.7 Kampala 51.6 10.1 25.0 8.9 48.4 10.2 45.2 10.2 Kamuli 7.9 6.1 1.3 2.6 0.0 N/A 6.6 5.6 Kamwenge 4.3 4.1 3.2 3.6 4.3 4.1 4.3 4.1 Kayunga 21.6 13.5 0.0 N/A 0.0 N/A 21.6 13.5 Kyenjojo 12.4 6.1 3.6 3.5 5.4 4.2 12.4 6.1 Lira 73.7 8.9 6.4 5.0 18.9 7.9 65.3 9.6 Masaka 69.5 9.3 56.8 10.0 65.3 9.6 63.2 9.8 Masindi 1.3 2.6 0.0 N/A 0.0 N/A 1.3 2.6 Mayuge 37.8 15.5 0.0 N/A 32.4 15.3 8.1 8.9 Mbale 48.9 10.2 21.5 8.4 49.5 10.2 46.2 10.2 Mbarara 62.8 9.8 49.4 10.6 59.8 10.1 57.0 10.5 Mukono 23.7 9.6 18.4 8.8 21.1 9.2 21.0 9.2 Rakai 42.7 11.3 29.3 10.4 33.3 10.7 28.0 10.2 Sironko 71.6 9.1 0.0 N/A 71.6 9.1 0.0 N/A Wakiso 65.8 10.7 9.7 6.9 42.3 11.6 57.3 11.3 Total 37.8 2.4 13.8 1.7 29.1 2.2 29.4 2.3
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Table F3. Positive Living, HIV Misconceptions and Knowledge of ABC among PLWHAs by District, LQAS Survey, Uganda, 2003. District Practicing 2 or more Reject all HIV Know at least 2 of the positive living ways misconceptions ABC % Confidence % Confidence % Confidence interval interval interval Arua 92.6 5.3 72.6 9.0 85.3 7.2 Bushenyi 78.1 8.3 22.9 8.5 61.5 9.8 Iganga 98.2 2.4 69.0 8.6 92.9 4.8 Kabale 51.3 11.3 42.9 11.1 61.0 11.0 Kampala 71.6 9.1 56.8 10.1 67.4 9.5 Kamuli 44.7 11.3 55.3 11.3 44.7 11.3 Kamwenge 58.9 10.0 28.7 9.2 58.1 10.1 Kayunga 47.4 16.1 34.2 15.3 55.3 16.0 Kyenjojo 57.9 9.1 76.1 7.9 79.2 7.8 Lira 61.7 9.9 46.3 10.1 60.0 9.9 Masaka 76.8 8.5 36.8 9.8 60.0 9.9 Masindi 55.3 11.3 64.5 10.8 44.7 11.3 Mayuge 55.3 16.0 60.5 15.8 55.6 16.5 Mbale 93.7 4.9 55.8 10.0 52.1 10.2 Mbarara 66.0 9.6 61.7 9.9 72.3 9.1 Mukono 26.3 10.0 59.2 11.1 56.6 11.2 Rakai 80.3 9.0 60.5 11.1 59.2 11.1 Sironko 100.0 N/A 94.7 4.5 64.8 9.9 Wakiso 84.2 8.3 75.0 9.8 69.3 10.5 Total 70.7 2.2 57.3 2.4 64.7 2.4
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Table F4. Sexual Behaviour and Condom Use Patterns in the Last 12 Months among PLWHAs by District, LQAS Survey, Uganda, 2003. Had sex in last Pattern of condom use District 12 months Always used condom Used condom in last sex % C.I. % C.I. % C.I. Arua 15.3 7.7 53.8 28.2 91.7 16.3 Bushenyi 49.5 10.1 63.0 14.1 69.0 14.2 Iganga 56.0 9.4 40.7 13.2 71.2 12.4 Kabale 28.9 10.3 14.3 15.3 30.4 19.4 Kampala 48.4 10.1 58.7 14.4 65.2 13.9 Kamuli 40.8 11.1 22.6 15.0 35.5 17.1 Kamwenge 37.2 9.8 31.4 15.6 38.2 16.6 Kayunga 47.4 16.1 23.5 20.8 37.5 25.5 Kyenjojo 45.4 9.4 45.8 14.3 55.3 14.4 Lira 35.8 9.7 21.2 14.2 42.4 17.1 Masaka 45.3 10.1 39.0 15.1 61.0 15.1 Masindi 28.9 10.3 45.5 21.3 52.4 21.6 Mayuge 48.6 16.8 43.8 25.1 68.8 23.5 Mbale 40.0 9.9 68.4 15.0 81.1 12.8 Mbarara 42.4 10.2 64.1 15.3 78.9 13.1 Mukono 28.9 10.3 50.0 21.4 63.6 18.6 Rakai 46.1 11.3 50.0 17.1 61.8 16.6 Sironko 30.8 9.6 19.4 7.0 100.0 N/A Wakiso 65.3 10.8 62.5 13.8 83.3 10.6 Total 41.0 2.4 48.7 3.9 63.4 3.8
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The World Bank (2000) Project Appraisal Document on a Proposed Credit to the Republic of Uganda for an HIV/AIDS Control Project
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Ministry of Health Uganda (2003) Uganda National Policy Guidelines for HIV Voluntary Counseling and Testing
Ministry of Health Uganda (2003) Uganda National Policy Implementation Guidelines for HIV Voluntary Counseling and Testing Services
Ministry of Health Uganda (2003) Policy for Reduction of the Mother-To-Child Hiv Transmission in Uganda
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