Faculty Bibliography

Reliable and valid assessment tools are crucial for measuring alcohol use expectancies (AUE) among youth living with HIV (YLHIV). In this paper, we assess the psychometric properties of the original 17-item East Africa Alcohol Expectancy Scale (AFEXS) among Ugandan YLHIV-a scale developed and validated by Woolf-King et al. for use among Uganda adults living with HIV. Specifically, we applied the measure to a sample of 100 Ugandan YLHIV enrolled in a substance use intervention. To analyze the psychometric properties, we conducted exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and convergent validity analyses. The resulting 15-item youth AFEXS scale differed from the 11-item adult version. The 15-item Youth AFEXS demonstrated high internal consistency (α = 0.85), aligning with theoretical expectations of a three-factor structure related to sexual expectancies (7 items; α = 0.89), negative expectancies (4 items; α = 0.72), and release of inhibition expectancies (4 items; α = 0.77). The global scale and sub-scales demonstrated satisfactory convergent validity through positive correlations measures of frequency of alcohol consumption in the past 12 months: global AFEXS (r = 0.617; p = 0.000), sexual expectancies (r = 0.583; p = 0.000), negative expectancies (r = 0.618; p = 0.000), and release expectancies (r = 0.596; p = 0.000). The study confirms the youth AFEXS as a reliable and valid tool for assessing AUE among Ugandan YLHIV.

BACKGROUND:Women engaged in commercial sex work (WESW) are exposed to behavioral, biological, and structural factors that exacerbate their risk of HIV infection and other sexually transmitted infections. While commercial sex work may appear voluntary, WESW are more likely to be constrained to selling sex due to limited viable alternatives. To effectively support this vulnerable group of women, it is critical to understand factors that facilitate and impede their decisions to transition from sex work into other careers or jobs. The current study explored women's decision to transition from sex work into other careers or jobs. METHODS:Face-to-face semi-structured in-depth interviews were conducted with 53 WESW aged 20-47 enrolled within the larger Kyaterekera study, a randomized clinical trial (N = 542) implemented in 19 geographical hotspots in the Southern region of Uganda. Participants were selected based on their level of intervention attendance (high/medium/low attendance) during the 12-month follow-up (Time 2). The interviews were conducted in Luganda the widely spoken language in the study area to explore the factors influencing women's decisions to transition from sex work to other jobs or careers. The main interview question used for this study was, "What are some of the factors that may influence whether you would transition from sex work to other jobs or vocations?" All interviews were audio-recorded, transcribed verbatim, and translated into English. Thematic analysis in Dedoose software was used to analyze the data. RESULTS:Participants reported three primary types of decisions, including considering leaving sex work, deciding to leave, and staying in sex work. The emerging themes from the interviews were categorized into individual and structural level facilitators and barriers to transitioning out of sex work. Individual-level factors included issues of stigma, discrimination, and aging as factors that facilitated women's decision to leave sex work. At the interpersonal level, physical and sexual violence was noted as a reason to leave sex work. At the structural level, stigma and discrimination (from community members) were identified as facilitators to leaving sex work. Income-related factors were identified mainly as barriers to leaving sex work. CONCLUSION/CONCLUSIONS:Our study highlights the complex decision-making processes among WESW as they navigate transitions to alternative jobs or careers. By advocating for multifaceted interventions and policies tailored to the diverse challenges faced by WESW, our study contributes to a more informed approach to supporting their transition out of sex work.

OBJECTIVES/OBJECTIVE:Adolescents living with HIV (ALHIV) have low viral suppression levels, with 1 in 3 ALHIV experiencing virologic failure, calling for more efforts to reverse these trends. We developed and validated a model that predicts the risk of virologic failure (VF) among ALHIV. STUDY DESIGN/METHODS:Cross-sectional study. METHODS:We used baseline data from 702 ALHIV enrolled in the Suubi + Adherence cluster-randomized clinical trial. Participants were aged 10-16 years, living with HIV and aware of their HIV status, and are living with a family. We developed a risk-prediction model for VF (viral load of ≥200 copies/mL) using sociodemographic, behavioral, psychological, economic, and treatment-related factors. LASSO logistic regression using 10-fold cross-validation with bootstrapping was used to select the predictors for the final model. Model performance was assessed by determining the discrimination using the area under the curve and calibration by drawing a calibration plot. RESULTS:Using a lambda value of 0.007, the final model had 24 predictors (and interaction terms). The predictors included the participants' age, sex, work status, stigma, depressive symptoms, adherence self-efficacy, HIV knowledge, duration with HIV, time spent on ART, communication with the caregiver, family cohesion, social support, orphanhood status, number of people in the household, HIV disclosure, years spent at the current residence, and household asset ownership. The model predicted VF with AUC of 73.8 (95 % CI: 68.3-78.0) and calibration slope of 0.985. CONCLUSIONS:We developed and validated a model to predict the risk of virologic failure among ALHIV in Uganda, demonstrating its potential utility in identifying individuals at elevated risk for VF. Future models could be refined by incorporating clinical characteristics such as CD4 count to further improve predictive accuracy.

OBJECTIVES/OBJECTIVE:Achieving optimal adherence to antiretroviral therapy (ART) and viral suppression is still insufficient for attaining the UNAIDS 95-95-95 target of 2030, especially among adolescents with HIV (AWHIV). This study sought to develop a model to predict poor adherence risk among AWHIV and identify associated risk factors. DESIGN/METHODS:We utilized machine learning to predict future ART adherence among AWHIV leveraging its ability to analyze complex, multidimensional data. METHODS:We leveraged a dataset from a 6-year (2012-2018) longitudinal randomized control trial (RCT) with 635 AWHIV in Uganda. We evaluated six machine learning models and retained one with the highest area under receiver operating characteristic (AUROC), and area under precision-recall curve (AUPRC). We further identified principal factors associated with ART adherence based on the best model. RESULTS:The random forest model outperformed others, with mean AUROC: 0.71 [BC 95% confidence interval (CI) (0.69-0.72)] and AUPRC: 0.55 (BC 95% CI 0.53-0.58). The principal risk factors of poor adherence were poor adherence history; poverty; biological relationship to caregiver; self-concept; savings confidence; duration on ART; frequency discussing sensitive topics with caregivers; household size; economic group assignment; and school enrollment. CONCLUSION/CONCLUSIONS:Our findings support potential use of machine learning methods and sociobehavioral data for predicting poor ART adherence risk among AWHIV. The predictive tool can help identify AWHIV at the highest risk of treatment failure, and enable early targeted interventions. However, the tool is still preliminary and its accuracy could be improved by incorporating HIV phenotypic and clinical data. CLINICAL TRIAL NUMBER/BACKGROUND:ClinicalTrials.gov ID:NCT01790373.

Sub-Saharan Africa (SSA) ranks lowest on the UNDP's Gender Inequality Index (GII), with a score of 0.56 out of 1 (1 being the worst), while Uganda scores 0.53, reflecting high gender inequality between males and females. These gender disparities are deeply rooted in longstanding inequitable gender norms and worsened by poverty. This study assessed a family economic empowerment intervention's impact on gender norm beliefs among HIV-orphaned adolescents in Uganda using three time-points data from the Suubi-Maka study, a cluster-randomized trial with 346 adolescent-caregiver dyads. Participants were randomized to control (n = 167) or treatment (n = 179) groups, with data collected at baseline, 12, and 24 months. We used mixed effects linear regression to assess the effect of the economic empowerment intervention on gender norms. Results indicated significant group-by-time interaction effects but non-significant independent group or time effects. Social support was positively significantly associated with equitable gender norms, emphasizing the role of supportive networks in facilitating change in gender norm beliefs. These findings suggest that economic interventions alone may not be sufficient for altering deeply entrenched gender norms, and future efforts should include more targeted, gender-transformative approaches.

We investigated how COVID-19-related disruptions influenced antiretroviral therapy (ART) adherence among young adults living with HIV (YALHIV) in Southern Uganda, a region with limited resources and high rates of HIV. Data were analyzed from 499 YALHIV aged 19 to 25, participating in the Suubi+Adherence-R2 COVID-19 Supplement study. The study measured COVID-19 disruptions using an 8-item Coronavirus Impact Scale and evaluated ART adherence through self-reported measures. Our analytical framework was informed by the Health Belief Model and generalized estimating equations were estimated. We find no statistically significant association between COVID-19 disruptions, as quantified by the COVID-19 Impact Score, and sub-optimal ART adherence (OR = 0.99, 95% CI [0.87-1.14]). However, findings revealed that being employed (OR = 1.99, 95% CI [1.07-3.71]) and older age (OR = 1.18, 95% CI [1.02-1.37]) was associated with higher likelihood of poor adherence highlighting the complex interplay between economic activity, working schedules, and health management. Other notable predictors included marital status, with cohabiting individuals showing decreased odds of poor adherence (OR = 0.25, 95% CI [0.08-0.74]) compared to single and separated YALHIV. These insights emphasize the need for multifaceted intervention strategies that consider both individual and systemic factors affecting ART adherence. Tailored interventions must address the socioeconomic challenges intensified by the pandemic and leverage the inherent resilience within this population to enhance ART adherence outcomes for YALHIV in challenging environments. Trial Registration ClinicalTrials.gov, ID: NCT01790373.

BACKGROUND:In many Sub-Saharan African countries (SSA), including Uganda, adolescent girls, especially those from low-income families, are disproportionately affected by inadequate menstrual hygiene management (MHM) facilities and supplies. This study assesses the impact of two interventions, including economic empowerment and family-strengthening interventions, on the self-esteem of adolescent girls and explores the moderating effects of cultural attitudes and menstrual hygiene knowledge. METHODS:We analyzed longitudinal data from a 3-arm Cluster Randomized Control Trial, Suubi4Her study, with a follow-up period of 24 months (2018-2022). A total of 1260 adolescent girls, aged 14-17 years, and living within a family were recruited from 47 schools within five geopolitical districts in Southwestern Uganda. The three study arms were: control (n = 16 schools, n = 408 students), Economic Empowerment using incentivized youth development accounts (YDA) (n = 16 schools, n = 471 students), and YDA + a family strengthening intervention that uses Multiple Family Group (MFG) meetings to address adolescent girls' and family health and wellbeing (n = 15 schools, n = 381 students). We used mixed-effect linear regression models to assess the impact of economic empowerment on self-esteem, measured by the Rosenberg Self-Esteem Scale, and the moderation effect of menstrual hygiene knowledge, measured by a nine-item scale, and cultural attitudes, measured by self-reported school absence during menstrual periods. RESULTS:(4) = 12.99, p = 0.011). Pairwise group comparisons at the different assessment time points showed no significant differences in self-esteem between YDA group and the control at baseline (β = 0.173 (-1.453, 1.108), p = 0.791), at 12 months (β = 0.372 (-0.893, 1.637), p = 0.565), and at 24 months (β = 0.153 (-0.904, 1.210), p = 0.777), indicating no significant effect of the YDA intervention alone on self-esteem. Similarly, no significant differences in self-esteem were found between the YDA + MFG group and the control at baseline (β=-0.299 (-1.713, 1.114), p = 0.678) and 12 months (β = 0.986 (-0.495, 2.468), p = 0.192). However, at 24-months follow-ups, the YDA + MFG group showed significantly higher self-esteem than the control (β = 1.282 (0.084, 2.480), p = 0.036). Additionally, those who reported school absenteeism due to cultural or religious reasons and received the YDA + MFG intervention reported higher self-esteem than usual care (β = 1.57 (0.07, 3.07), p = 0.004). No significant moderation by menstrual hygiene knowledge or cultural attitude was detected. CONCLUSION/CONCLUSIONS:The YDA + MFG intervention and natural age progression improved self-esteem, though reliance on self-reported data may introduce bias. However, the YDA intervention alone did not significantly improve self-esteem at any assessment point.

This study explores the factors that shape the savings behaviors of women engaged in sex work (WESW) in southwestern Uganda, with a particular focus on the intersection of caregiving responsibilities and economic vulnerability. Drawing on qualitative data from the Kyaterekera study-an intervention that combined economic empowerment strategies (savings, financial literacy, and mentorship) with HIV risk reduction-we examine how WESW navigate financial decision-making in the context of structural and social constraints. While participants demonstrated motivation and resilience in pursuing financial stability, they encountered significant and intersecting barriers, including fluctuating income, caregiving demands, gendered norms, and the absence of formal social support systems. Findings reveal that caregiving is not merely a personal role but a structurally marginalized identity that shapes economic behavior in profound ways as these caregiving responsibilities intersect with factors such as marital status, household composition, and urban-rural location to produce differentiated financial challenges. Despite these constraints, participants engaged in strategic saving to meet essential needs, respond to emergencies, and invest in long-term goals such as homeownership and their children's education. These insights underscore the importance of adopting an intersectional approach to economic empowerment-one that accounts for the diverse and overlapping realities of WESW. Tailored interventions that integrate financial literacy, peer mentoring, and potentially self-help groups can more effectively address both individual and structural barriers. By centering caregiving within economic empowerment strategies, programs can better support the long-term financial autonomy and well-being of WESW and their families.

Despite high prevalence of emotional and behavioral difficulties (EBDs) among adolescents living with HIV (ALHIV), there are limited randomized trials assessing the impact of interventions on these outcomes. We assessed the impact of two evidence-based interventions in a three-arm cluster randomized controlled trial (RCT) where nine clinics were randomized to one of three study arms: (1) Usual Care; (2) Group-Cognitive Behavioral Therapy (G-CBT) + Usual Care; and (3) Multiple Family groups (MFG) + Usual Care. We utilized mixed effects models to assess the effect of the intervention on EBDs. While the main effect of the intervention was not significant, χ2(2) = 0.43, p = 0.806, the main effects for time χ2(2) = 32.47, p < 0.001, and intervention-time interaction, χ2 (2) = 59.59, p < 0.001, were statistically significant, suggesting reduction in the EBDs across the groups overtime. Pairwise comparisons showed that in the G-CBT group, EBDs reduced at three months [contrast = -7.59 (CI: -8.20 - -6.99), <0.001] and 6-months [contrast = -8.11 (CI: -12.64 - -3.57), <0.001] compared to baseline. No statistically significant pairwise comparisons across time were observed in the control group, which confirmed that the significant group-by-time interactions were driven by our intervention effects. Findings that G-CBT improved EBDs in this pilot trial highlight the potential efficacy of this intervention in addressing EBDs among ALHIV. However, further studies are warranted to investigate prolonged exposure to MFG as well as combination of MFG and G-CBT to understand the nuances that will ultimately inform the development of tailored effective interventions for addressing EBDs in this vulnerable population.