Kiryandongo: 2018 PLACE Assessment Objectives

• Know the local epidemic • Assess the local response • Prioritize gaps for follow-up

Fieldwork

Engaged 57 stakeholders 

Trained 21 people 

Identified 8 priority prevention areas 

Identified 538 venues in PPAs 

Visited & profiled 249 venues 

Interviewed & tested 600 people

 Sources: Esri, HERE, Garmin, USGS, Intermap, INCREMENT P, NRCan, Esri Japan, METI, Esri China, (Hong Kong), Esri Korea, Esri (Thailand), NGCC, © OpenStreetMap contributors, and the GIS User Community Priority prevention areas (PPA) are areas identified by district stakeholders where the risk of HIV Identified 15 people who were transmission is likely to be higher. The map shows the location of venues where people go to meet new sexual HIV-positive partners in each PPA. The location of venues was identified by geographic positioning system (GPS) or, if the venue was not visited, based on a description of its location. 

Assessed HIV prevention/ treatment for 600 people Most commonMost common types oftypes venues of venues 120 The number and 103 101 100 type of venues varied by district. 80 69 The graph shows the number of 60 46 venues in the 40 35 district for each 23 of the six types of Number of venues 20 venues that were the most common 0 there. Other bar Bar with sex Restaurant Guest house Local Repair shop on site video/TV PLPriorities for LocalA AIDSCE Control Efforts rooms People meet new sexual partners at venues

MeetingMeeting sexual sexual partners partners at sites:sites: Perceptions Perceptions of venue of venue A venue informant is a person informants informants knowledgeable about the venue, such as a bar manager. At each venue, a venue 100 informant was asked about the types of 90 people who come to the venue to meet 80 70 sexual partners and about activities related 60 to meeting sexual partners there, such as 49 50 whether someone helps facilitate these 40 sexual partnerships and whether staff meet 30 22 17 sexual partners at the venue. The graph 20 12 10 9 shows the percentage of venues, among the

Percentage of of venues Percentage 10 0 approximately 300 venues that were visited, People meet Sex workers find People have Female staff Male staff meet Someone helps where the venue informant reported that partners here partners here sex here meet partners partners patrons find each activity occurs. partners

The PLACE team interviewed and tested approximately 600 people in each district. The surveys showed differences between older and younger men and between women who work at the venues and women who come to the venues as patrons. See below. HIV prevalence among these four groups is shown on the next page. Younger men at venues (< age 35) Older men at venues (> age 35) Demographics % Demographics % Mean age (in years) 26.0 Mean age (in years) 45.1 Has children 33.7 Has children 29.6 Married/living with partner 52.8 Married/living with partner 81.2 Did not complete primary school 42.3 Did not complete primary school 51.5 Unemployed 83.1 Unemployed 85.4 Sexual Network Sexual Network 2+ sexual partners, past 4 weeks 40.2 2+ sexual partners, past 4 weeks 35.5 With 2 or more sexual partners in the past year 72.4 With 2 or more sexual partners in the past year 63.7 New partner in past year 70.6 New partner in past year 54.1 Believes main partner has other partners 22.7 Believes main partner has other partners 13.4 Ever had anal sex 5.7 Ever had anal sex 1.4 Condom Use Condom Use No condom, last vaginal sex 71.0 No condom, last vaginal sex 89.2 2+ partners past 4 weeks, no condom last sex 63.0 2+ partners past 4 weeks, no condom last sex 63.6 Reports that condoms are easy to get 59.9 Reports that condomes are easy to get 55.6 Vulnerabilities Vulnerabilities < 15 at first sex 16.0 < 15 at first sex 17.5 Living at venue 5.9 Living at venue 9.1 Ever spent night in jail 29.4 Ever spent night in jail 29.6 Ever raped 5.0 Ever raped 2.2 Exchanged sex for money in past 3 months 6.8 Exchanged sex for money in past 3 months 0.0 Ever paid cash for sex 37.1 Ever paid cash for sex 17.8 Daily alcohol consumption 23.2 Daily alcohol consumption 37.5 Visits venue 4+ times per week 55.7 Visits venue 4+ times per week 54.5 Women who work at venues Female patrons at venues Demographics % Demographics % Mean age (in years) 28.9 Mean age (in years) 32.6 Has children 31.2 Has children 31.4 Married/living with partner 49.5 Married/living with partner 58.4 Did not complete primary school 69.0 Did not complete primary school 66.5 Unemployed 77.2 Unemployed 93.6 Sexual Network Sexual Network 2+ sexual partners, past 4 weeks 13.6 2+ sexual partners, past 4 weeks 8.4 With 2 or more sexual partners in the past year 31.2 With 2 or more sexual partners in the past year 27.5 New partner in past year 40.2 New partner in past year 29.9 Believes main partner has other partners 41.6 Believes main partner has other partners 34.2 Ever had anal sex 0.0 Ever had anal sex 3.1 Condom Use Condom Use No condom, last vaginal sex 76.2 No condom, last vaginal sex 85.8 2+ partners past 4 weeks, no condom last sex 43.3 2+ partners past 4 weeks, no condom last sex 67.0 Reports that condoms are easy to get 36.4 Reports that condoms are easy to get 33.3 Vulnerabilities Vulnerabilities < 15 at first sex 13.6 < 15 at first sex 12.1 Living at venue 24.8 Living at venue 16.6 Ever spent night in jail 9.0 Ever spent night in jail 9.4 Ever raped 7.5 Ever raped 8.1 Exchanged sex for money in past 3 months 22.0 Exchanged sex for money in past 3 months 5.8 Ever paid cash for sex 9.7 Ever paid cash for sex 6.0 Daily alcohol consumption 14.0 Daily alcohol consumption 9.4 Visits venue 4+ times per week 79.1 Visits venue 4+ times per week 56.2 HIV prevalence and condom cascades

DistributionDistributions of HIV infections ofacross HIV PPAs infections across PPAs 35.0 33.0 120%

30.0 100% 24.4 This graph shows the advantage of a 25.0 80% strategy to focus on the PPAs where 20.0 the number of infections is greatest. 16.3 60% The PPAs with the largest number 15.0

Percentage Percentage of persons with HIV who could be 9.5 40% 10.0 8.1 reached at venues is shown first 4.7 4.1 5.0 20% in the graph, with the remaining 0.0 PPAs sorted by number of persons 0.0 0% Kiryandongo ToC Truck Apodorwa TrC Mutunda TrC Port TrC Bweyale ToC ToC Kapundo TrC infected. Stop HIV infections Cumulative percentage Total number of individuals tested: 600

HIV prevalence by groupHIV prevalence, by group 6.0 5.4

5.0

4.0 This graph shows the prevalence of HIV among younger versus older men and among women who work at the venue 3.0 versus those who visit as patrons. The graph illustrates the 2.2 2.2 high risk among women who work at the venue. 2.0 1.3

1.0 Percentage of of Percentage positiveHIV individuals 0.0 HIV prevalence, by sex and age Female workers Men over the age Men under the age Female patrons of 35 of 35 4.5 HIV prevalence, by sex and age 4.1 HIV prevalence, 4.0by sex and age 3.5 3.5 4.5 4.1 2.9 3.0 4.0 3.5 This graph shows the prevalence of HIV infection 2.5 2.2 3.5 positive individuals - among the approximately 600 men and women tested 2.9 2.0 3.0 during visits to the venues at busy times. The estimates 1.5 2.5 2.2 are weighted1.1 to reflect sampling probabilities. The positive individuals - 1.0 2.0 graph highlights differences in HIV prevalence by age 0.5 1.5 for men and women. Confidence intervals are provided 1.1 Percentage of HIV 0.0 0.0 0.0 0.0 below the graph. 1.0 15-18 19-24 25-34 35-80 0.5 Age

Percentage of HIV 0.0 0.0 0.0 0.0 Women N=191 Men N=406 15-18 19-24 25-34 35-80 Age 95% confidence limits adjusted for sampling weights: Men: 15─18 (0.00-0.00), 19─24 (0.00-0.00), 25─34 (0.07-6.87); 35─80 (0.00-4.35) Women N=191 Men N=406 Women: 15─18 (0.00-0.00), 19─24 (0.00-3.23), 25─34 (0.00-6.19), 35─80 (0.00-10.60)

95% confidence limits adjusted for sampling weights: Men: 15─18 (0.00-0.00), 19─24 (0.00-0.00), 25─34 (0.07-6.87); 35─80 (0.00-4.35) Women:Prevention 15─18 (0.00-0.00), cascade: 19─24 (0.00-3.23), Condom 25─34 (0.00-6.19), availability 35─80 (0.00-10.60) and use Prevention cascade: Condom availability and Prevention cascade: Condom availability and use among Prevention cascade: Condom availability and use among amongmen whomen paid who for sex paid or who for reported sex or two who or more reported partners two usewomen among who received women cash, who gifts, receivedor favors for sex cash, in the gifts, or morein the partnerspast 4 weeks in the past 4 weeks orpast favors 12 months for sex in the past 12 months

120.0% 120.0% 100.0% 100.0% 100.0% 100.0%

80.0% 80.0% 55.5% 60.0% 60.0% 44.7% 43.5% 38.1%

Percentage 40.0% Percentage 40.0% 28.8% 28.8%

20.0% 20.0% 4.4% 4.6% 0.0% 0.0% Men who have Report easy to Ever used a Used condoms in Used condoms Women who Report condoms Ever used a Used condoms in Used condoms ever paid for sex get condoms condom past 6 months consistently in received cash, are easy to get condom past 6 months consistently in or have had 2+ past 6 months gifts, or favors for past 6 months partners in past 4 sex in the past 12 weeks months

The condom cascades above demonstrate the gap in the availability of condoms and—among people who say that it is easy to get condoms—the gap in consistent use. The graph showing the condom cascade for men is for those who have ever paid for sex or who have had more than two sexual partners in the past four weeks. The risk of infection and onward transmission is likely to be higher for these men than for other men. The graph showing the condom cascade for women is for those who have received cash, gifts, or favors in return for sex in the past 12 months. These women are also at increased risk of acquiring and transmitting HIV. Men and women who are living with HIV are included in these figures. Gaps in prevention services

PercentagePercentage of venues of with venues on-site with prevention on-site servicesprevention in the past services 3 months in the past 3 months 100 90 80 70 64 Prevention 60 services at 50 venue 36 40 29  Complete 30 17 Some 20 11 9 None 10 0 0 None Any Condoms HIV testing Education Peer Posters program

These maps zoom in on a PPA or part of a PPA to illustrate the differences in availability of prevention at venues. The map on the left shows the PPA with a higher proportion of coverage. The map on the right shows the PPA with a lower proportion of coverage. “Complete” coverage was defined as condoms being available (either for sale or for free), HIV testing on site in the past three months, and education (either posters or peer education or other educational outreach) in the past three months. “Some” coverage indicates that the venue has education, testing, or condoms. Venues without education, testing, or condoms are categorized as “None.”

PercentagePercentage never never using using a a condom during during the past the 3 months past 3 months

Women who live at the venue 43.3%

Middle-aged men 40.7% Many people use condoms Men who have sex with men 35.6% inconsistently; some people do not use them at all. The graph People who are HIV-positive 31.0% on the left shows the percentage Women who received cash for sex 29.3% of each risk group that reported Group never using a condom in the past Women who received gifts or favors for sex 25.2% three months. Men with 2+ partners, past 4 weeks 23.5%

Men who paid for sex 18.4%

Transgender women 0.0%

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0% 50.0% Percentage never using a condom

Acknowledgments: We thank the United States Agency for International Development and the United States President’s Emergency Plan for AIDS Relief for their support of this work.  We thank the District PLACE Steering Committee for their support and leadership, as follows: Dr. Mutyaba Imaam, DHO; Ms. Rosemary Katusiime, District HIV Focal Person; Mr. Linos Ngom’Pek, RDC; Mr. Ben Tumugabinwe, DISO; Mr. Kyategeka David, Assistant CAO- Health; and Mr. Rashid Okecha, Secretary for Health. They guided the implementation of PLACE in the district, identified research assistants who collected data, and supported efforts to test people for HIV and link them to care.  We wish to acknowledge the leadership of the core PLACE team from Makerere University: Professor Freddie Ssengooba, Professor Lynn Atuyambe, Dr. Simon Kasasa, Mr. Steven Ssendagire, Ms. Milly Nattimba, Ms. Susan Babirye, and Dr. Florence Nankya.

This publication was produced with the support of the United States Agency for International Development (USAID) under the terms of MEASURE Evaluation cooperative agreement AID-OAA-L-14-00004. MEASURE Evaluation is implemented by the Carolina Population Center, University of North Carolina at Chapel Hill in partnership with ICF International; John Snow, Inc.; Management Sciences for Health; Palladium; and Tulane University. Views expressed are not necessarily those of USAID or the United States government. FS-18-322i