Synthesis, Consolidation and Building Consensus on Key and Priority Population Size Estimation Numbers in Uganda FINAL REPORT October 2019 TABLE OF CONTENTS TABLE OF CONTENTS 2 Operational Definitions 3 List of Acronyms and Abbreviations 5 Acknowledgement 6 Executive Summary 7 1.0 INTRODUCTION 7 1.1 Background and Rationale 7 1.2 Purpose 8 1.3 Specific Objectives 9 2.0 METHODOLOGY 9 2.1 Overview 9 2.2 Literature Review Methodology 10 2.3 Selection of Studies for Meta-Analysis 11 2.4 Modelling KPs Size Estimates 12 2.5 Methods for Reaching Consensus on the Estimates 15 3.0 FINDINGS 1: HIV/AIDS IN UGANDA 17 3.1 Epidemiology and Trends of HIV in Uganda 17 3.2 The Role of Key Populations in the HIV Epidemic in Uganda 18 4.0 FINDINGS 2: KEY POPULATIONS 20 4.1 Key Populations: Definitions, Operational Typology and Structure 20 4.2 Eligible Studies for Meta-Analysis on Population Size of key populations in Uganda 27 4.3 Estimates of Sizes of the Different Types of Key Populations 33 4.4 Mapping of predicted estimates in Uganda 44 4.5 Strengths and Weaknesses of Size Estimation Methodologies 46 5.0 DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS 47 BIBLIOGRAPHY 48 APPENDICES 53 Operational Definitions Bisexual: A person who is attracted to and /or has sex with both men and women, and who identifies with this as a cultural identity. The terms men who have sex with both men and women or women who have sex with both women and men should be used unless individuals or groups self-identify as bisexual. Concentrated epidemic: HIV has spread rapidly in one or more populations but is not well established in the general population. Typically, the prevalence is over 5% in subpopulations while remaining under 1% in the general population, although these thresholds must be interpreted with caution. In a concentrated HIV epidemic, there is still the opportunity to focus HIV prevention, treatment, care, and support efforts on the most affected subpopulations, while recognizing that no subpopulation is fully self-contained. Fisher folk/fishing Community: A community that is substantially dependent on, or substantially engaged in the harvest or processing of fishery resources to meet social and economic needs. Gender: “The social attributes and opportunities associated with being male and female and the relationships between women and men and girls and boys, as well as the relations between women and those between men. These attributes, opportunities and relationships are socially constructed and are learned through socialization processes. They are context/time-specific and changeable. Gender determines what is expected, allowed and valued in a woman or a man in a given context. In most societies, there are differences and inequalities between women and men in responsibilities assigned, activities undertaken, access to and control over resources, as well as decision-making opportunities”. Generalized epidemic: An epidemic that is self-sustaining through heterosexual transmission. In a generalized epidemic, HIV prevalence usually exceeds 1% among pregnant women attending antenatal clinics. Injecting drug user: The term ‘injecting drug users’ is preferable to ‘drug addicts’ or ‘drug abusers’, which are derogatory terms that are not conducive to fostering the trust and respect required when engaging with people who use drugs. Note that the term intravenous drug users’ is incorrect because subcutaneous and intramuscular routes may be involved. A preferable term that places the emphasis on people first is ‘person who injects drugs’. A broader term that may apply in some situations is a person who uses drugs. Key populations: UNAIDS considers gay men and other men who have sex with men, sex workers and their clients, transgender people, people who inject drugs and prisoners and other incarcerated people as the main key population groups. These populations often suffer from punitive laws or stigmatizing policies, and they are among the most likely to be exposed to HIV. Their engagement is critical to a successful HIV response everywhere—they are key to the epidemic and key to the response. Countries should define the specific populations that are key to their epidemic and response based on the epidemiological and social context. The term key populations at higher risk also may be used more broadly, referring to additional populations that are most at risk of acquiring or transmitting HIV, regardless of the legal and policy environment. *Each country should define the specific populations that are key to their epidemic and response based on the epidemiological and social context. Lesbian: A woman attracted to other women. She may or may not be having sex with women, and a woman having sex with women may or may not be a lesbian. The term women who have sex with women should be used unless individuals or groups self-identify as lesbians. Men who have sex with men: Males who have sex with males, regardless of whether or not they also have sex with women or have a personal or social gay or bisexual identity. This concept is useful because it also includes men who self-identify as heterosexual but who have sex with other men. People who inject drugs: People who take in psychoactive drugs intravenously for non-medical purposes. People who use drugs: People who consume psychoactive drugs in non-injecting forms such as smoking, chewing or sniffing. Priority populations: Populations which by virtue of demographic factors (age, gender, ethnicity, income level, education attainment or grade level, marital status) or behavioral factors or health care coverage status or geography are at increased risk of HIV. People in prisons and other closed settings: There are many different terms used to denote places of detention, which hold people who are awaiting trial, who have been convicted or who are subject to other conditions of security. Similarly, different terms are used for those who are detained. In this guidance document, the term “prisons and other closed settings” refers to all places of detention within a country, and the terms “prisoners” and “detainees” refer to all those detained in criminal justice and prison facilities, including adult and juvenile males and females, during the investigation of a crime, while awaiting trial, after conviction, before sentencing and after sentencing. This term does not formally include people detained for reasons relating to immigration or refugee status, those detained without charge, and those sentenced to compulsory treatment and to rehabilitation centers. Risk: Risk is defined as the risk of exposure to HIV or the likelihood that a person may acquire HIV. Behaviors, not membership of a group, place individuals in situations in which they may be exposed to HIV, and certain behaviors create, increase or perpetuate risk. Risk factor: An aspect of personal behavior or lifestyle or an environmental exposure which based on epidemiological evidence is known to be associated with HIV transmission or acquisition. Sex worker: Sex work is the provision of sexual services for money or goods. Sex workers are women, men and transgendered people who receive money or goods in exchange for sexual services, and who consciously define those activities as income generating even if they do not consider sex work as their occupation. Transgender: An umbrella term to describe people whose gender identity and expression does not conform to the norms and expectations traditionally associated with their sex at birth. Transgender people include individuals who have received gender reassignment surgery, individuals who have received gender-related medical interventions other than surgery (e.g. hormone therapy) and individuals who identify as having no gender, multiple genders or alternative genders. Vulnerability: Vulnerability refers to unequal opportunities, social exclusion, unemployment, or precarious employment and other social, cultural, political, and economic factors that make a person more susceptible to HIV infection and to developing AIDS. The factors underlying vulnerability may reduce the ability of individuals and communities to avoid HIV risk and may be outside the control of individuals. Women who have sex with women: The term women who have sex with women (including adolescents and young women) includes not only women who self-identify as lesbian or homosexual and have sex only with other women, but also bisexual women and women who self-identify as heterosexual, but who have sex with other women. List of Acronyms and Abbreviations ADPG AIDS Development Partner Group AIDS Acquired Immune Deficiency Syndrome AMICAALL Alliance of Mayors and Municipal Leaders on HIV/AIDS in Africa BBS Bio-behavioural survey CHAU Community Health Alliance Uganda CIs Confidence Intervals CRC Capture-Recapture Method DHS Demographic and Health Survey DRC Democratic Republic of the Congo FSWs Female sex workers HIV Human Immuno-deficiency Virus IBBS Integrated Biological and Behavioral Surveillance IDUs Injecting drug users KP Key Populations KPSE Key Populations Size Estimation Study KP-TWG Key Population Technical Working Group MakSPH Makerere University School of Public Health MARPs Most at risk populations MCMC Markov Chain Monte Carlo MoH Ministry of Health MoT Modes of Transmission Study MSM Men who have sex with men PEPFAR Presidential Emergency Fund for AIDS Relief PLACE Priorities for Local AIDS Control Efforts PMSE Programmatic Mapping and Size Estimation Study PWDs Persons with disabilities PWIDs People who inject drugs RDS Response Driven Sampling SE Standard Error TWG Technical Working Group UAC Uganda AIDS Commission UKPC Uganda Key Population Consortium UNAIDS The Joint United Nations Programme on HIV/AIDS UPS Uganda Prisons Service UPHIA Uganda Population-based HIV Impact Assessment survey WHO World Health Organization WOC Wisdom of the Crowds Acknowledgement The synthesis, consolidation and building consensus on key and priority population size estimation study was commissioned by the Uganda AIDS Commission (UAC) and the Ministry of Health (MoH) with technical and financial support from the UNAIDS Uganda Country Office and implemented by a team of consultants from the Makerere University School of Public Health.