Uganda - Social dynamics, HIV risk, and use of HIV services in high-prevalence fishing communities in Rakai, Uganda
In Rakai DIstrict, Uganda, fishing villages on Lake Victoria have been identified as settings with extremely high HIV incidence and prevalence, risk behaviors and mobility. Recent surveillance of 2,500 individuals in 3 Rakai fishing communities showed an HIV prevalence of 35-43% and incidence of ~3.9/100 person-years. Preliminary evidence from Rakai and similar settings indicates these rates may be driven by complex dynamics of sex work (often related to the fishing economy), high rates of sexual risk behaviors, low priority accorded to HIV prevention, extensive networks of inter- and intra-community relationships, high rates of mobility and seasonal migration, and suboptimal interactions between health workers and key populations. The objective of this study is to use mixed methods research to better understand HIV transmission and potential prevention dynamics in high-prevalence fishing villages in Rakai, Uganda. The project is conducted in collaboration with the Rakai Health Sciences Program (RHSP), an organization with a longstanding collaboration with Johns Hopkins. A substantial qualitative component will include: (a) in-depth interviews with local fishermen, female fish traders/sellers, sex workers/bar girls, bar/venue owners, and HIV-related service delivery providers, (b) focus group discussions with men and women in the local community, and (c) unstructured observations in fishing markets and beaches, drinking establishments and sex work venues (bars, lodges), and HIV-related services. Qualitative findings will be triangulated with existing data from quantitative surveys and clinical data sources, and results will be used to develop additional quantitative measures that can be included in the Rakai community cohort study. Findings from this study will be used to tailor existing PEPFAR-supported combination HIV prevention, care and treatment programs, as well as demand generation to optimize uptake, for these settings.
Global Health PI/Mentor: Caitlin Kennedy
It’s difficult to summarize such a dynamic and complex experience in a few short sentences, even paragraphs. “How was your trip?” I am asked, but I have yet to find a satisfying, quick answer. Much of my work involved applying the skills I have acquired in the past year – interviewing and transcribing and analyzing and composing – and it was satisfying to realize how much we actually learned (and retained!) in such a short period of time.
My practicum was based out of the Rakai Health Science Program (RHSP) in Rakai District, Uganda and focused on a qualitative analysis of values and preferences related to HIV self-testing (HIVST) among fishing and mainland communities. In 2014, UNAIDS issued the 90-90-90 goal which asserts that by 2020, 90% of all people living with HIV will know their HIV status; 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy; and 90% of all people receiving antiretroviral therapy will reach viral suppression. An important first step to achieving this goal is to increase the availability and uptake of HIV testing services, specifically in high-prevalence populations. The Rakai District has been identified as one of these "hotspot" regions, with estimated HIV prevalence of 20-40% in some communities. Theoretically, HIVST could provide a preferable testing option for individuals who may prefer testing in private, rather than seeking services at a public clinic.
Coming into this project, it was important to me to be useful. In just a few years in the global health field I had already seen how too often well-intended foreigners enter communities only to become burdens on the individuals whom they claim to support. I wanted to avoid participating in this problematic phenomenon as much as possible; I wanted to contribute in some real (if small) way.
With these concerns in mind, I felt good about working at RHSP for a number of reasons. First, RHSP is a research facility that has been renowned for groundbreaking work in the epidemiology of HIV/AIDS in sub-Saharan Africa since 1987. It is operated by Ugandan clinicians and public health practitioners and is a powerhouse of academic and programmatic research in the region. This history appealed to me; I was eager to learn. Second, RHSP and JHSPH have been working together for almost two decades. I have met many JHSPH faculty who have worked in Rakai and now we share colleagues and experiences in a unique way. This institutional relationship also enabled me to begin working with colleagues before even leaving Baltimore, and gave me confidence to hit the ground running once I arrived (it should be noted that much, if not all of this, is also to the credit of my PI, Dr. Caitlin Kennedy). Third, the longer I was at RHSP the more I discovered; there is so much going on at all times. The more I learned, the more I wanted to know. A summary report I wrote on this HIVST research was presented to the World Health Organization in July and will inform their updated HIV testing guidelines released later this year (2016). I am eager to see how RHSP and others around the world implement and evaluate these new strategies for HIV testing and treatment and am hopeful that I’ll return to Rakai in the future to work with them on some of these opportunities.
One of the prompts for this reflection is “What pushed you out of your comfort zone?” My first reaction is everything; everything pushes me out of my comfort zone, initially. I’m a curious introvert with homebody tendencies and motion sickness issues (hello, minibuses!), but I love learning about new people and different perspectives and get excited about things like health behavior models. This practicum solidified my professional goals to continue working in Global Public Health to understand the social and behavioral factors influencing health outcomes around the world. I feel very fortunate to have had the opportunity to meet and work with some great people at RHSP, and am continually impressed by their commitment to quality research and community health. This field placement was an incredibly valuable experience that I would not have been able to accept without GHEFP funding, and for that I am very grateful.