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Self-Reported Adherence to Antiretroviral Therapy (ART) Among Women Engaged in Commercial Sex Work in Southern Uganda

Kiyingi, Joshua; Nabunya, Proscovia; Kizito, Samuel; Nabayinda, Josephine; Nsubuga, Edward; Bahar, Ozge Sensoy; Jennings Mayo-Wilson, Larissa; Namuwonge, Flavia; Nattabi, Jennifer; Magorokosho, Natasja; Tozan, Yesim; Witte, Susan S; Ssewamala, Fred M
We examined the correlates of self-reported adherence to antiretroviral therapy (ART) among women engaged in commercial sex work (WESW) in Uganda. We used baseline data from a longitudinal study, which recruited 542 WESW in Southern Uganda. We used nested regression models to determine the individual and family, and economic level correlates of self-reported adherence. Study findings show that older age (OR = 1.07, 95% CI = 1.013, 1.139), secondary education (OR = 2.01, 95% CI = 1.306, 3.084), large household size (OR = 1.08, 95% CI = 1.020, 1.136), high family cohesion (OR = 1.06, 95% CI = 1.052, 1.065), and high financial self-efficacy (OR = 1.07, 95% CI = 1.006, 1.130) were associated with good self-reported adherence to ART. Married women (OR=-0.39, 95% CI = 0.197, 0.774), depression (OR = 0.85, 95% CI = 0.744, 0.969), alcohol use (OR = 0.72, 95% CI = 0.548, 0.954), ever been arrested (OR = 0.58, 95% CI = 0.341, 0.997), and high household assets ownership (OR = 0.48, 95% CI = 0.313, 0.724) were associated with poor self-reported adherence to ART. Findings suggest a need to adopt a multi-level approach to address gaps in ART adherence among WESW.
PMID: 36066764
ISSN: 1573-3254
CID: 5309862

Economic Abuse and Care-seeking Practices for HIV and Financial Support Services in Women Employed by Sex Work: A Cross-Sectional Baseline Assessment of a Clinical Trial Cohort in Uganda

Jennings Mayo-Wilson, Larissa; Yen, Bing-Jie; Nabunya, Proscovia; Bahar, Ozge Sensoy; Wright, Brittanni N; Kiyingi, Joshua; Filippone, Prema L; Mwebembezi, Abel; Kagaayi, Joseph; Tozan, Yesim; Nabayinda, Josephine; Witte, Susan S; Ssewamala, Fred M
Economic hardship is a driver of entry into sex work, which is associated with high HIV risk. Yet, little is known about economic abuse in women employed by sex work (WESW) and its relationship to uptake of HIV prevention and financial support services. This study used cross-sectional baseline data from a multisite, longitudinal clinical trial that tests the efficacy of adding economic empowerment to traditional HIV risk reduction education on HIV incidence in 542 WESW. Mixed effects logistic and linear regressions were used to examine associations in reported economic abuse by demographic characteristics, sexual behaviors, HIV care-seeking, and financial care-seeking. Mean age was 31.4 years. Most WESW were unmarried (74%) and had less than primary school education (64%). 48% had savings, and 72% had debt. 93% reported at least one economic abuse incident. Common incidents included being forced to ask for money (80%), having financial information kept from them (61%), and being forced to disclose how money was spent (56%). WESW also reported partners/relatives spending money needed for bills (45%), not paying bills (38%), threatening them to quit their job(s) (38%), and using physical violence when earning income (24%). Married/partnered WESW (OR = 2.68, 95% CI:1.60-4.48), those with debt (OR = 1.70, 95% CI:1.04-2.77), and those with sex-work bosses (OR = 1.90, 95% CI:1.07-3.38) had higher economic abuse. Condomless sex (β = +4.43, p < .05) was higher among WESW experiencing economic abuse, who also had lower odds of initiating PrEP (OR = .39, 95% CI:.17-.89). WESW experiencing economic abuse were also more likely to ask for cash among relatives (OR = 2.36, 95% CI:1.13-4.94) or banks (OR = 2.12, 95% CI:1.11-4.03). The high prevalence of HIV and economic abuse in WESW underscores the importance of integrating financial empowerment in HIV risk reduction interventions for WESW, including education about economic abuse and strategies to address it. Programs focusing on violence against women should also consider economic barriers to accessing HIV prevention services.
PMID: 35510547
ISSN: 1552-6518
CID: 5253272

Costing of a Multiple Family Group Strengthening Intervention (SMART-Africa) to Improve Child and Adolescent Behavioral Health in Uganda

Tozan, Yesim; Capasso, Ariadna; Namatovu, Phionah; Kiyingi, Joshua; Damulira, Christopher; Nabayinda, Josephine; Bahar, Ozge Sensoy; McKay, Mary M; Hoagwood, Kimberly; Ssewamala, Fred M
Reliable cost estimates are key to assessing the feasibility, affordability, and cost-effectiveness of interventions. We estimated the economic costs of a multiple family group (MFG) intervention-child and adolescent mental health evidence-based practices (CAMH-EBP) implemented under the SMART-Africa study, seeking to improve family functioning and reduce child and adolescent behavior problems-delivered through task-shifting by community health workers (CHWs) or parent peers (PPs) in school settings in Uganda. This prospective microcosting analysis was conducted from a provider perspective as part of a three-armed randomized controlled trial of the MFG intervention involving 2,391 participants aged 8-13 years and their caregivers in 26 primary schools. Activity-specific costs were estimated and summed, and divided by actual participant numbers in each study arm to conservatively calculate total per-child costs by arm. Total per-child costs of the MFG-PP and MFG-CHW arms were estimated at US$346 and US$328, respectively. The higher per-child cost of the MFG-PP arm was driven by lower than anticipated attendance by participants recruited to this arm. Personnel costs were the key cost driver, accounting for approximately 70% of total costs because of intensive supervision and support provided to MFG facilitators and intervention quality assurance efforts. This is the first study estimating the economic costs of an evidence-based MFG intervention provided through task-shifting strategies in a low-resource setting. Compared with the costs of other family-based interventions ranging between US$500 and US$900 in similar settings, the MFG intervention had a lower per-participant cost; however, few comparisons are available in the literature. More costing studies on CAMH-EBPs in low-resource settings are needed.
PMID: 35189589
ISSN: 1476-1645
CID: 5175022

Prevalence and predictors of HIV and sexually transmitted infections among vulnerable women engaged in sex work: Findings from the Kyaterekera Project in Southern Uganda

Kiyingi, Joshua; Nabunya, Proscovia; Bahar, Ozge Sensoy; Mayo-Wilson, Larissa Jennings; Tozan, Yesim; Nabayinda, Josephine; Namuwonge, Flavia; Nsubuga, Edward; Kizito, Samuel; Nattabi, Jennifer; Nakabuye, Fatuma; Kagayi, Joseph; Mwebembezi, Abel; Witte, Susan S; Ssewamala, Fred M
INTRODUCTION:Women engaged in sex work (WESW) have an elevated risk of the human immunodeficiency virus (HIV) and sexually transmitted infections (STI). Estimates are three times higher than the general population. Understanding the predictors of HIV and STI among WESW is crucial in developing more focused HIV and STI prevention interventions among this population. The study examined the prevalence and predictors of HIV and STI among WESW in the Southern part of Uganda. METHODOLOGY:Baseline data from the Kyaterekera study involving 542 WESW (ages 18-55) recruited from 19 HIV hotspots in the greater Masaka region in Uganda was utilized. HIV and STI prevalence was estimated using blood and vaginal fluid samples bioassay. Hierarchical regression models were used to determine the predictors of HIV and STI among WESW. RESULTS:Of the total sample, 41% (n = 220) were found to be HIV positive; and 10.5% (n = 57) tested positive for at least one of the three STI (Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis) regardless of their HIV status. Older age (b = 0.09, 95%CI = 0.06, 0.13, p≤0.001), lower levels of education (b = -0.79, 95%CI = -1.46, -0.11, p≤0.05), fewer numbers of children in the household (b = -0.18, 95%CI = -0.36, -0.01), p≤0.05), location (i.e., fishing village (b = 0.51, 95%CI = 0.16, 0.85, p≤0.01) or small town (b = -0.60, 95%CI = -0.92, -0.28, p≤0.001)), drug use (b = 0.58, 95%CI = 0.076, 1.08, p≤0.05) and financial self-efficacy (b = 0.05, 95%CI = -0.10, 0.00, p≤0.05), were associated with the risk of HIV infections among WESW. Domestic violence attitudes (b = -0.24, 95%CI = -0.42, -0.07, p≤0.01) and financial distress (b = -0.07, 95%CI = -0.14, -0.004, p≤0.05) were associated with the risk of STI infection among WESW. CONCLUSION:Study findings show a high prevalence of HIV among WESW compared to the general women population. Individual and family level, behavioural and economic factors were associated with increased HIV and STI infection among WESW. Therefore, there is a need for WESW focused HIV and STI risk reduction and economic empowerment interventions to reduce these burdens.
PMCID:9522279
PMID: 36174054
ISSN: 1932-6203
CID: 5351192

Family Economic Empowerment, Family Social Support, and Sexual Risk-Taking Behaviors Among Adolescents Living With HIV in Uganda: The Suubi+Adherence Study

Shato, Thembekile; Nabunya, Proscovia; Byansi, William; Nwaozuru, Ucheoma; Okumu, Moses; Mutumba, Massy; Brathwaite, Rachel; Damulira, Christopher; Namuwonge, Flavia; Bahar, Ozge Sensoy; Neilands, Torsten B; Ssewamala, Fred M
PURPOSE/OBJECTIVE:This study examined the effect of a family economic empowerment (EE) intervention and family support on sexual risk-taking behaviors among adolescents living with HIV in rural Uganda. METHODS:We used data from the Suubi + Adherence study, a longitudinal cluster randomized clinical trial of 702 adolescents living with HIV aged 10-16 years. Participants were randomly assigned to either the control arm (n = 358) receiving bolstered standard of care or a treatment arm (n = 344) receiving bolstered standard of care plus the family EE intervention. We used mixed-effects models to examine the effect of the EE intervention and family support on sexual risk-taking behaviors at the baseline, 12 months, and 24 months after intervention initiation. RESULTS:Adolescents in both the intervention and control groups did not differ significantly in their sexual risk-taking attitudes at the baseline and over the 24-month follow-up period. Higher levels of caregiver social support were significantly associated with a decrease in attitudes toward sexual risk-taking (ß = -.40, 95%CI = -.51, -.29). More frequent parent-child communication was significantly associated with increased negative sexual risk-taking attitudes (ß = .21, 95%CI = .16, .26). CONCLUSIONS:Although we find no direct relationship between family EE and attitudes related to sexual risk-taking behaviors, we find that a supportive family environment can promote positive attitudes related to sexual risk-taking behaviors. The effectiveness of sexual risk reduction interventions would be enhanced by engaging families and strengthening supportive relationships between adolescents and their caregivers.
PMID: 33812750
ISSN: 1879-1972
CID: 4838752

Predictors of Depressive Symptoms and Post Traumatic Stress Disorder Among Women Engaged in Commercial Sex Work in Southern Uganda

Nabunya, Proscovia; Byansi, William; Damulira, Christopher; Bahar, Ozge Sensoy; Jennings Mayo-Wilson, Larissa; Tozan, Yesim; Kiyingi, Joshua; Nabayinda, Josephine; Braithwaite, Rachel; Witte, Susan S; Ssewamala, Fred M
This study examined the factors associated with depressive symptoms and post traumatic depressive disorder (PTSD) among economically vulnerable women engaged in commercial sex work (WESW) in southern Uganda. Baseline data from a longitudinal cluster randomized study involving 542 self-identified WESW (18-55 years), recruited from 19 HIV hotspots were analyzed. Hierarchical linear regression modelling was utilized to estimate individual, family-level and economic-level predictors of depressive symptoms and PTSD. Family cohesion, sex work stigma, HIV status, financial distress, household assets, number of children and number of household income earners, were associated with PTSD. Similarly, family cohesion, number of people in the household, HIV status, sex work stigma, financial distress, and household assets, were associated with depressive symptoms. Women engaged in commercial sex work are at a higher risk of HIV and poor mental health outcomes. Sex work stigma and financial distress elevate levels of depressive symptoms and PTSD, over and above an individual's HIV status. Family and economic-level factors have the potential to mitigate the risk of poor mental health outcomes. As such, integrating stigma reduction and economic strengthening components in the programming targeting WESW-a key population, may be critical to address their mental health outcomes.
PMID: 33636517
ISSN: 1872-7123
CID: 4795192

Prevalence and correlates of depressive symptoms among high school adolescent girls in southern Uganda

Nabunya, Proscovia; Damulira, Christopher; Byansi, William; Muwanga, Joelynn; Bahar, Ozge Sensoy; Namuwonge, Flavia; Ighofose, Eloho; Brathwaite, Rachel; Tumwesige, Wilberforce; Ssewamala, Fred M
BACKGROUND:In sub-Saharan Africa (SSA), adolescent girls and young women are three times more likely than boys to have depressive disorders. Understanding adolescents' unique and common vulnerabilities and protective factors is essential for the development of appropriate interventions and programming focused on child and adolescent mental health. This paper examines the prevalence and predictors of depressive symptoms among high school adolescent girls in southern Uganda. METHODS:Baseline data from a longitudinal cluster randomized study involving 1260 adolescent girls (14-17 years), recruited from 47 secondary schools were utilized. Depressive symptoms were estimated using the 21-item Beck's Depression Inventory. Hierarchical linear regression modelling was utilized to estimate key predictors of depressive symptoms among adolescent girls. RESULTS:Of the total sample, 16.35% (n = 206) reported severe depressive symptoms and almost one in every three adolescent girls interviewed (29.68%, n = 374) reported moderate symptoms. These symptoms were more prevalent among older adolescents (16 years and above). In addition, family relationships, social support, as well as measures of psychological wellbeing (self-concept and self-esteem) were all associated with lower levels of depressive symptoms. Hopelessness was associated with higher levels of depressive symptoms among adolescent girls. CONCLUSION/CONCLUSIONS:Findings from this study indicate a high prevalence of depressive symptoms, especially among older adolescent girls. In addition, family support factors and adolescents' psychological wellbeing were associated with low levels of depressive symptoms -pointing to the need to strengthen family functioning and adolescent's psychological wellbeing to mitigate risks. Taken together, findings support increasing calls for early screening and detection of depressive symptoms to facilitate timely referral to care and treatment. Findings may also inform the development and incorporation of gender-specific mental health components in programming targeting adolescent girls, in low-resource communities in SSA. TRIAL REGISTRATION/BACKGROUND:This trial was prospectively registered with ClinicalTrials.gov (registration number: NCT03307226 ) on 11 October 2017.
PMID: 33238965
ISSN: 1471-2458
CID: 4680822

Gender, HIV knowledge and prevention attitudes among adolescents living with HIV participating in an economic empowerment intervention in Uganda

Nabunya, Proscovia; Byansi, William; Muwanga, Joelynn; Damulira, Christopher; Brathwaite, Rachel; Namuwonge, Flavia; Bahar, Ozge Sensoy; Ssewamala, Fred M
HIV disproportionately affect adolescent girls and young women in sub-Saharan Africa. In Uganda, the HIV prevalence is four times higher in adolescent girls compared to boys. This study examined gender, HIV general and clinical knowledge, and prevention attitudes among adolescents living with HIV in Uganda. Data from a cluster randomized clinical trial were analyzed. A total of 702 adolescents (average age of 12.4) were randomized to either a control arm receiving bolstered standard of care or the treatment arm receiving bolstered standard of care plus a family economic empowerment intervention to support medication adherence. Ordinary Least Squares models that adjust for clustering of adolescents within health clinics were conducted. No gender differences were observed in HIV knowledge and prevention attitudes at baseline. However, at 12-months follow-up, boys were more likely than girls to report correct HIV general knowledge (d = 0.21), clinical knowledge (d = 0.48), and favorable prevention attitudes (d = 0.27). The intervention was not associated with any of the outcomes. Given the high HIV prevalence among adolescents, specifically girls, there is need to develop and/or tailor existing programs and interventions that equip adolescent girls with comprehensive knowledge and prevention attitudes, that are culturally appropriate, to reduce HIV transmission and reinfection within this population.
PMID: 33172305
ISSN: 1360-0451
CID: 4665072

The impact of discomfort with HIV status and hopelessness on depressive symptoms among adolescents living with HIV in Uganda

Cavazos-Rehg, Patricia; Xu, Christine; Borodovsky, Jacob; Kasson, Erin; Byansi, William; Nabunya, Proscovia; Bahar, Ozge Sensoy; Ssewamala, Fred M
Introduction: Discomfort with and reluctance to disclose HIV status can lead to depression, social isolation, and poor medication adherence; we examined relationships among these variables within a sample of adolescents living with HIV in Uganda. Methods: We used baseline data from the Suubi + Adherence study, which recruited a total of 702 adolescents (ages 10-16 years) living with HIV in southwestern Uganda. Structural equation models were conducted separately among in-school adolescents and out-of-school adolescents to assess associations between discomfort level with HIV status and depressive symptoms and if this association was mediated by hopelessness. Results: Out-of-school adolescents had significantly higher depression scores compared with those in-school youth (M = 6.24 vs. M = 5.03, p < 0.001). Although high discomfort level with HIV status was significantly associated with higher depression scores among both in-school adolescents and out-of-school adolescents, this association among out-of-school adolescents (B = 0.49, 95%CI: 0.19, 0.79), was more substantial than for in-school adolescents (B = 0.10, 95%CI: 0.03, 0.17). Discussion: One's discomfort with their HIV status and the extent to which they are hopeful about the future can contribute to the development of depressive symptoms and these factors need to be considered in the development of assessments and interventions for the treatment of depression among adolescents living with HIV.
PMID: 32551822
ISSN: 1360-0451
CID: 4484932

The role of family factors in antiretroviral therapy (ART) adherence self-efficacy among HIV-infected adolescents in southern Uganda

Nabunya, Proscovia; Bahar, Ozge Sensoy; Chen, Bin; Dvalishvili, Daji; Damulira, Christopher; Ssewamala, Fred M
BACKGROUND:Adolescents living with HIV in sub-Saharan Africa are a vulnerable group at the intersection of poverty and health disparities. The family is a vital microsystem that provides financial and emotional support to achieve optimal antiretroviral therapy (ART) adherence. In this study, we explore the association between family factors and ART adherence self-efficacy, a significant psychological concept playing a critical role in ART adherence. METHODS:Data from an NIH-funded study called Suubi + Adherence, an economic empowerment intervention for HIV positive adolescents (average age = 12.4 years) in southern Uganda was analyzed. We conducted multilevel regression analyses to explore the protective family factors, measured by family cohesion, child-caregiver communication and perceived child-caregiver support, associated with ART adherence self-efficacy. RESULTS:The average age was 12.4 years and 56.4% of participants were female. The average household size was 5.7 people, with 2.3 children> 18 years. Controlling for sociodemographic and household characteristics, family cohesion (β = 0.397, p = 0.000) and child-caregiver communication (β = 0.118, p = 0.026) were significantly associated with adherence self-efficacy to ART. CONCLUSION/CONCLUSIONS:Findings point to the need to strengthen family cohesion and communication within families if we are to enhance adherence self-efficacy among adolescents living with HIV. TRIAL REGISTRATION/BACKGROUND:This trial was registered with ClinicalTrials.gov (registration number: NCT01790373) on 13 February 2013.
PMCID:7077174
PMID: 32183762
ISSN: 1471-2458
CID: 4352622