https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(97)01063-5.pdf

Hiv-1 infection associated with abnormal vaginal flora morphology and bacterial vaginosis

There has been considerable interest in understanding what may have led to Uganda's dramatic decline in HIV prevalence, one of the world's earliest and most compelling AIDS prevention successes. Survey and other data suggest that a decline in multi-partner sexual behavior is the behavioral change most likely associated with HIV decline. It appears that behavior change programs, particularly involving extensive promotion of “zero grazing” (faithfulness and partner reduction), largely developed by the Ugandan government and local NGOs including faith-based, women’s, people-living-with-AIDS and other community-based groups, contributed to the early declines in casual/multiple sexual partnerships and HIV incidence and, along with other factors including condom use, to the subsequent sharp decline in HIV prevalence. Yet the debate over “what happened in Uganda” continues, often involving divisive abstinence-versus-condoms rhetoric, which appears more related to the culture wars in the USA than to African social reality.

/pdf/uganda-s-hiv-prevention-success-the-role-of-sexual-behavior-gt0rm582b0.pdf

Uganda's HIV prevention success: the role of sexual behavior change and the national response.

Traditionally, fertility and family planning research and programs have focused on women. With the expansion of the field to include reproductive health following the 1994 International Conference on Population in Cairo, the more appropriate focus for most reproductive health components appears to be the sexually active couple. This review of studies of couples and reproductive health outcomes examines reports of objective reproductive events, of attitudes and reproductive intentions, of the effect of each partner's attitudes and intentions, of reproductive outcomes, and of the effectiveness of interventions that target couples compared with those that target one partner or the other. For couples' statements about reproductive events, studies throughout the world typically show identical reports less than 90 percent of the time. Concordance between partners on subjective matters is in the range of 60 to 70 percent. Data based on reports of reproductive intentions from both partners have been shown to lead to better predictions of behavior than have data from only one partner. Finally, reproductive health interventions that target couples are found to be more effective than those directed to only one sex. The evidence clearly justifies a focus on couples.

Couples and reproductive health: a review of couple studies.

The effectiveness of HIV voluntary counseling and testing (VCT) in reducing HIV risk behaviors in developing countries was assessed using meta-analytic methods. A standardized protocol was used for searching, acquiring, and extracting study data and meta-analyzing the results. Seven studies met the inclusion criteria. VCT recipients were significantly less likely to engage in unprotected sex when compared to behaviors before receiving VCT, or as compared to participants who had not received VCT [OR 1.69; 95%CI 1.25-2.31]. VCT had no significant effect on the number of sex partners [OR 1.22; 95%CI 0.89-1.67]. While these findings provide only moderate evidence in support of VCT as an effective prevention strategy, neither do they negate the need to expand access to HIV testing and counseling services. Such expansion, however, must be accompanied by rigorous evaluation in order to test, refine and maximize the preventive benefits of learning one's HIV infection status through HIV testing and counseling.

HIV voluntary counseling and testing and behavioral risk reduction in developing countries: a meta-analysis, 1990--2005.

To monitor the HIV-1 epidemic in western Uganda and the possible impact of interventions age-specific trends in HIV-1 prevalence during 1991-1997 among antenatal clinic (ANC) attenders in Fort Portal where a comprehensive AIDS control program has been implemented since 1991 were analyzed and results compared with outputs from a mathematical model simulating the HIV-1 epidemic in the country. Scenarios with and without behavior change were modelled. Sentinel surveillance data were compared with data from a population-based HIV-1 serosurvey at the study site which was conducted in early 1995. Data from 3271 ANC attenders found greater education and single status to be risk factors for HIV-1 infection. A significant decrease of risk for women with secondary school education over time was observed while the risk for illiterate women remained high. Among the 1045 women aged 15-19 years education and marital status-adjusted HIV-1 prevalence declined steadily from 32.2% to 10.3% over the period. For the 1010 women aged 20-24 years prevalence increased until 1993 from 19.9% to 31.7% then declined thereafter to 21.7% in 1997. These declining trends of HIV-1 prevalence probably reflect a reduced HIV-1 incidence attributable to changes in behavior. No clear trends of HIV-1 prevalence were found in older women.

Reductions in risk behaviour provide the most consistent explanation for declining HIV-1 prevalence in Uganda.

OBJECTIVE--To define the geographical distribution of HIV infection and the community characteristics associated with HIV prevalence in a rural population of Uganda. DESIGN--Seroprevalence survey and interviews of the population aged 13 years and older in 21 randomly selected clusters. SETTING--Rural population of Rakai district, south west Uganda. SUBJECTS--1292 adults, of whom 594 men and 698 women gave a blood sample and answered the questionnaire. MAIN OUTCOME MEASURES--HIV status determined by ELISA and western blotting in relation to community characteristics. RESULTS--The weighted seroprevalence of HIV for the district was 12.6% with prevalence by cluster varying from 1.2% to 52.8%. Seroprevalence was highest in main road trading centres (men 26%, women 47%), intermediate in rural trading villages on secondary roads (men 22%, women 29%), and lowest in rural agricultural villages (men 8%, women 9%). For both men and women, multiple regression showed a strong negative association between cluster seroprevalence and the proportion of the population employed in agriculture (beta = -0.677 for men, -0.807 for women). Among women, cluster seroprevalence increased with a higher proportion of the population reporting multiple sex partners (beta = 0.814), external travel (beta = 0.579), and injections (beta = 0.483). CONCLUSIONS--Community characteristics, particularly the proportion of the population in agriculture, are associated with HIV prevalence and can be used for targeting interventions. The seroprevalences of HIV suggest spread of infection from main road trading centres, through intermediate trading villages, to rural agricultural villages.

https://www.bmj.com/content/bmj/303/6813/1303.full.pdf

Dynamics of spread of HIV-I infection in a rural district of Uganda.

Objective : To determine the incidence of infection with HIV-1 and the risk factors associated with seroconversion in three geographical strata of a rural Ugandan district. Design : Serological, sociodemographic, and behavioural surveys of everyone aged 13 or more in 21 randomly selected communities at baseline and 20 one year later. Setting : Rural population of Rakai district, south-western Uganda, residing in main road trading centres, secondary trading villages, and agricultural villages. Subjects : In 1989, 1292 adults provided a blood sample and interview data; one year later, 778 survivors (77%) who had been seronegative at baseline provided follow up data. Main outcome measures : Incidence of HIV infection in relation to individual characteristics and risk factors, including place of residence. Results : Incidence of HIV infection in all adults was 2.1/100 person years of observation (SE 0.5 (95% confidence interval 1.1 to 3.1)); in people aged 15-39 the incidence was 3.2/100 person years. Incidence was highest in men and women aged 20-24 (9.2/100 person years (3.9) and 6.8/100 person years (2.9) respectively). Risk factors significantly associated with seroconversion were age 24 and under and two or more sexual partners. Between the surveys the proportion of all respondents reporting high risk behaviour (two or more partners) significantly increased from 8.9% to 12.3%. Conclusions : Despite preventive programmes and substantial knowledge about AIDS the incidence of HIV infection remains high in this rural population. Prevention aimed at vulnerable rural communities is urgently needed to contain the HIV epidemic.

/pdf/incidence-of-hiv-1-infection-in-a-rural-region-of-uganda-2cqic14r76.pdf

Incidence of HIV-1 infection in a rural region of Uganda

Focus group interviews about AIDS in Rakai district of Uganda

Recent Changes in Behavior and Practices in Relation to the HIV Epidemic in Rakai, Uganda

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Dynamics of spread of HIV-I infection in a rural district of Uganda.

Incidence of HIV-1 infection in a rural region of Uganda

Focus group interviews about AIDS in Rakai district of Uganda

Recent Changes in Behavior and Practices in Relation to the HIV Epidemic in Rakai, Uganda