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Introduction Serodiscordant couples are a priority population for delivery of new HIV prevention interventions in Africa. An integrated strategy of delivering time‐limited, oral pre‐exposure prophylaxis (PrEP) to uninfected partners in serodiscordant couples as a bridge to long‐term antiretroviral treatment (ART) for infected partners has been implemented in East Africa, nearly eliminating new infections. We conducted a qualitative evaluation of the integrated strategy in Uganda, to better understand its success. Methods Data collection consisted of 274 in‐depth interviews with 93 participating couples, and 55 observations of clinical encounters between couples and healthcare providers. An inductive content analytic approach aimed at understanding and interpreting couples’ experiences of the integrated strategy was used to examine the data. Analysis sought to characterize: (1) key aspects of services provided; (2) what the services meant to recipients; and (3) how couples managed the integrated strategy. Themes were identified in each domain, and represented as descriptive categories. Categories were grouped inductively into more general propositions based on shared content. Propositions were linked and interpreted to explain “why the integrated strategy worked.” Results Couples found “couples‐focused” services provided through the integrated strategy strengthened partnered relationships threatened by the discovery of serodiscordance. They saw in services hope for “getting help” to stay together, turned joint visits to clinic into opportunities for mutual support, and experienced counselling as bringing them closer together. Couples adopted a “couples orientation” to the integrated strategy, considering the health of partners as they made decisions about initiating ART or accepting PrEP, and devising joint approaches to adherence. A couples orientation to services, grounded in strengthened partnerships, may have translated to greater success in using antiretrovirals to prevent HIV transmission. Conclusions Various strategies for delivering antiretrovirals for HIV prevention are being evaluated. Understanding how and why these strategies work will improve evaluation processes and strengthen implementation platforms. We highlight the role of service organization in shaping couples’ experiences of and responses to ART and PrEP in the context of the integrated strategy. Organizing services to promote positive care experiences will strengthen delivery and contribute to positive outcomes as antiretrovirals for prevention are rolled out.

Hormonal contraceptives are used widely but their effects on HIV-1 risk are unclear. We aimed to assess the association between hormonal contraceptive use and risk of HIV-1 acquisition by women and HIV-1 transmission from HIV-1-infected women to their male partners. In this prospective study, we followed up 3790 heterosexual HIV-1-serodiscordant couples participating in two longitudinal studies of HIV-1 incidence in seven African countries. Among injectable and oral hormonal contraceptive users and non-users, we compared rates of HIV-1 acquisition by women and HIV-1 transmission from women to men. The primary outcome measure was HIV-1 seroconversion. We used Cox proportional hazards regression and marginal structural modelling to assess the effect of contraceptive use on HIV-1 risk. Among 1314 couples in which the HIV-1-seronegative partner was female (median follow-up 18·0 [IQR 12·6–24·2] months), rates of HIV-1 acquisition were 6·61 per 100 person-years in women who used hormonal contraception and 3·78 per 100 person-years in those who did not (adjusted hazard ratio 1·98, 95% CI 1·06–3·68, p=0·03). Among 2476 couples in which the HIV-1-seronegative partner was male (median follow-up 18·7 [IQR 12·8–24·2] months), rates of HIV-1 transmission from women to men were 2·61 per 100 person-years in couples in which women used hormonal contraception and 1·51 per 100 person-years in couples in which women did not use hormonal contraception (adjusted hazard ratio 1·97, 95% CI 1·12–3·45, p=0·02). Marginal structural model analyses generated much the same results to the Cox proportional hazards regression. Women should be counselled about potentially increased risk of HIV-1 acquisition and transmission with hormonal contraception, especially injectable methods, and about the importance of dual protection with condoms to decrease HIV-1 risk. Non-hormonal or low-dose hormonal contraceptive methods should be considered for women with or at-risk for HIV-1. US National Institutes of Health and the Bill & Melinda Gates Foundation.

Sex workers of all genders have a high risk of HIV acquisition and are a priority population for HIV pre-exposure prophylaxis (PrEP). We aimed to assess current oral PrEP use and associated factors among cisgender female sex workers (FSW) in two Ugandan cities. We administered a survey questionnaire to 236 HIV-negative FSW in the cities of Mbale and Mbarara from January to March 2020. The survey was nested in a quasi-experimental study to assess the effect of peer education and text message reminders on the uptake of regular sexually transmitted infection (STI) and HIV testing. Using interviewer-administered questionnaires, we obtained data on current self-reported tenofovir-based oral PrEP use. We used modified Poisson regression with robust standard errors to evaluate the factors associated with current oral PrEP usage. Nearly 70% of FSWs reported taking an HIV test during the past three months. Among the respondents, 33% (33/100) in Mbale and 67% (91/136) in Mbarara reported having ever heard of PrEP. However, only 9.7% (23/236) self-reported currently taking oral-PrEP. In Mbarara, FSWs were twice as likely to be aware of or use oral PrEP than those in Mbale (adjusted prevalence ratio [aPR] 2.33; 95% confidence interval (CI) 1.19-3.97; p = 0.01). Additionally, current use was positively associated with attainment of secondary (aPR 2.50; 95% CI: 1.14-5.45; p = 0.02) or tertiary education (aPR 3.12; 95% CI: 1.09-8.96; p = 0.03). PrEP use in this cohort of FSWs was low and was associated with location and level of education. To increase PrEP uptake among FSWs, targeted educational campaigns and implementation studies are needed, particularly for those with lower levels of education.

Background Women living with HIV (WLHIV) require more frequent cervical cancer screening than HIV negative women. However, uptake of cervical cancer screening services integrated into HIV care at most rural public health facilities in Eastern Uganda is low, below 50%. This is attributed to low cervical cancer screening literacy among rural WLHIV: limited ability to access, understand, and apply cervical cancer screening information. There is a need for evidence-based, context-specific, theory-informed strategies that target multi-level barriers and facilitators of cervical cancer literacy among these women. This study used research evidence, theory, and stakeholder engagement in selecting strategies for improving cervical cancer screening literacy among rural WLHIV. Methods This qualitative study applied research evidence to the Behavior Change Wheel (BCW) and co-design approach. The eight steps of the BCW included: 1) defining the problem in behavioral terms, 2) selecting the target behavior, 3) specifying the target behavior, 4) identifying what needs to change, 5) identifying intervention functions, 6) identifying policy categories, 7) identifying Behavior Change Techniques (BCT), and 8) identifying the mode of delivery. We conducted four parallel co-design sessions with 12 health care providers and 16 rural women at steps 3 and 4 of the BCW. Results We formulated eighteen behavioral targets that were linked to all Capability, Opportunity, and Motivation-Behavior (COM-B) behavioral determinants. Nine behavioral targets were selected under the education, persuasion, enablement, and training intervention functions, as well as the communication/marketing and service provision policy categories. We identified ten most appropriate BCTs and four modes of delivery, which translated into four strategies, namely: 1) trained cervical cancer screening peer educators, 2) cervical cancer screening education video, 3) improved cervical cancer screening IEC charts, and 4) train midwives to prepare small portions of acetic acid for individual patient screening. Conclusions The BCW provided a comprehensive framework that integrated a co-design approach and applied research evidence in selecting context-specific and feasible strategies for improving cervical cancer screening literacy among rural WLHIV. Future research is needed to design and evaluate these strategies.

Background Periodic testing of female sex workers (FSW) for sexually transmitted infections (STIs) is a core component of global and national responses to achieve population-level STI elimination. We conducted a qualitative study to explore barriers and facilitators of regular syphilis and HIV testing among FSW in Uganda. Methods Within a quasi-experimental study among 436 FSW to assess the effect of peer education and text message reminders on uptake of regular STI and HIV testing among FSW, we conducted 48 qualitative interviews in four cities in Uganda from August–December 2018. We purposively selected FSW who tested for syphilis and HIV every 3–6 months; 12 FSW were interviewed in each city. Sex worker interviews explored: 1) reasons for periodic syphilis and HIV testing; 2) barriers and facilitators of testing; 3) experiences of testing; and 4) challenges faced while seeking testing services. Data were analyzed using thematic content analysis. Results Thematic analysis revealed individual- and health system-level barriers and facilitators of testing. For syphilis, barriers were a) interpersonal stigma, low perceived severity of syphilis and testing misconceptions (individual); and b) judgmental provider attitudes, paucity of facilities offering syphilis testing, stockouts of test kits and high cost (health system). Facilitators were c) desire to remain healthy, get married and have children, knowing the benefits of early treatment, influence of male partners/clients and normative testing behaviors (individual); and d) sex worker clinics offering dual syphilis/HIV testing (health system). For HIV, barriers included: a) internalized stigma (individual); and b) unfavorable clinic hours, stigma, discrimination, and unfriendly provider (health system). Facilitators were a) motivations to stay healthy and attract clients, habitual testing, self-efficacy, doubts about accuracy of negative test results, and use of post-exposure prophylaxis (individual); and d) availability of testing facilities (health system). Syphilis and HIV had similar testing barriers and facilitators. Conclusions HIV programs are likely to be important entry points for syphilis testing among FSW. Multi-level interventions to address testing barriers should consider focusing on these service delivery points. Extending the dual syphilis and HIV testing approach to FSW may improve testing uptake for both infections at public health facilities and decrease population-level incidence.

IntroductionCervical cancer screening literacy among rural women living with HIV (WLHIV), the ability to access, understand, appraise, and apply cervical cancer screening information to use cervical cancer screening services, is affected by individual factors including low educational attainment, low socioeconomic status, poor cervical cancer risk perception, fear, misconceptions, and beliefs, as well as interpersonal, community, and health facility barriers. However, rural public health facilities have limited resources that limit their ability mitigate these challenges. This research identified barriers and facilitators of healthcare providers' responsiveness to cervical cancer screening literacy needs of rural WLHIV in Eastern Uganda.MethodsThis was a descriptive qualitative study that involved conducting 15 Key Informant Interviews with all individuals involved in planning, communicating, and providing cervical cancer screening services at 4 purposively selected rural public health facilities in Eastern Uganda. Data were collected using a guide developed based on the organizational Health Literacy responsiveness framework. This framework was used to derive deductive categories (domains and sub-domains) during thematic analysis, and barriers and facilitators were inductively identified from the interviews.ResultsBarriers included non-involvement of health workers and affected women in planning, limited funding, few trained health workers, long waiting times, limited space, limited communication modalities, inadequate Information Education and Communication (IEC) materials, IEC materials not translated to the local language, challenges with addressing misconceptions, and language barriers. Facilitators included support from implementing partners, free cervical cancer screening services, integration of cervical cancer screening into HIV care, consumer-centered care, clear pathways and navigation support, using peers during health education, availability of IEC materials, using simple, local language during education sessions, and health worker facilitation.ConclusionStrategies targeted at the identified factors can improve health care providers' responsiveness to the cervical cancer screening literacy needs of rural WLHIV in Eastern Uganda.

The uptake of cervical cancer screening services among rural Women Living with HIV (WLHIV) attending several rural public facilities in Eastern Uganda is low at less than 50% of the target. This gap is largely influenced by low screening literacy among these women, difficulties in accessing, understanding and applying cervical cancer screening information due to multiple barriers, including limited education, low socioeconomic status, misconceptions, and fear. Therefore, context-specific and culturally appropriate strategies are needed to overcome these barriers. This study engaged rural WLHIV in Eastern Uganda to co-design three strategies to improve their cervical cancer screening literacy. This participatory research combined the User-Centered Design (UCD) approach with co-design workshops to design the three strategies. Participants included 16 rural WLHIV from four rural public health facilities in Mayuge and Namayingo districts who had participated in prior studies that identified and selected these strategies. This process involved the ideation and implementation phases of the UCD approach. It was led by a medical illustrator and a Sexual and a Behavioral Change Communication specialist, supported by two healthcare providers. Two IEC charts, one on the importance of cervical cancer screening and the other addressing key misconceptions regarding cervical cancer screening. Both IEC charts had colorful pictures, and few texts in local language, Luganda, explaining the pictures. Two peer educators were trained to provide cervical cancer screening education, address misconceptions about cervical cancer screening, and encourage women to undergo cervical cancer screening. A ten-minute cervical cancer screening education video was designed, comprising a midwife providing cervical cancer screening education and a trained peer educator interacting with a client. Integrating co-design and UCD approaches facilitated the design of context-specific strategies that incorporated preferences for rural WLHIV and targeted barriers to cervical cancer-screening literacy among these women.

Background Several rural public health facilities in East Central Uganda have sub-optimal, below 50%, levels of uptake of cervical cancer screening services among women with HIV. This is attributed to low cervical cancer screening literacy: limited ability to access, understand, appraise, and apply cervical cancer screening information. This research identified multi-level (health facility, community, interpersonal and individual) barriers, and facilitators of accessing, understanding, and applying cervical cancer screening information among rural women with HIV attending rural public health facilities in East Central Uganda to inform interventions. Methods We conducted ten Focus Group Discussions with rural women aged 25–49 years with HIV attending four selected rural public health facilities: thirty women who had ever screened for cervical cancer and thirty women who had never screened for cervical cancer across different age categories. Data was collected using a guide based on the Integrated model of health literacy. Thematic analysis was used for analysis. Competences (accessing, understanding and applying cervical cancer screening information) and categories of factors (health system, community, interpersonal and individual factors) of the integrated model of health literacy were deductively derived whereas barriers and facilitators were deductively derived from women’s statements. Results Lack of communication materials and inability to access information were health facility and individual barriers of accessing cervical cancer screening information respectively. Facilitators of accessing information were access to information at health facility, community, and interpersonal levels and women’s ability to access information. Barriers and facilitators of understanding cervical cancer information were related to communication materials, provision of health education and women’s concentration during health education. Barriers and facilitators of applying cervical cancer screening information were related to communication and provision of cervical cancer screening services at health facility level, and interpersonal level from peers, partners and other family members as well as women’s ability to: understand information and access to cervical cancer screening services at individual level. Conclusions This study emphasizes the influence of multi-level factors on cervical cancer screening literacy among rural women with HIV attending rural public health facilities in East Central Uganda. Improving uptake of cervical cancer screening services among these women requires multi-level interventions.

Background Globally, female sex workers (FSW) are disproportionately affected by HIV and other sexually transmitted infections (STIs). However, uptake of STI and HIV testing services among FSW in sub-Saharan Africa remains low. We aimed to assess the effect of FSW-led peer education and text message reminders on 3-monthly syphilis and HIV testing among FSW in Uganda. Methods Between September 2019 and February 2020, we implemented weekly peer education sessions and bi-monthly SMS reminders for FSW in Mbarara (intervention city). Peer education sessions were implemented by 20 FSW, who received five days of basic training as peer educators. We held monthly meetings with peer educators throughout the six-month implementation period. FSW in Mbale (control city) continued to receive standard of care consisting of HIV testing outreach campaigns, and facility-based testing. Using a quasi-experimental design in one intervention city, and one control city, we conducted pre- and post- questionnaire-based surveys on recent syphilis and HIV testing behavior among FSW in July-October 2018, and March 2020. We compared proportions and prevalence ratios at baseline and follow-up using chi-square tests and negative binomial regression. Results We conducted 436 interviews (200 before/236 after) with FSW. At baseline similar proportions reported taking an HIV test (57 % vs. 54 %; p  = 0.72), and a syphilis serology test (35 % vs. 39 %; p  = 0.67) in the intervention and control cities, respectively, in the prior three months. After the intervention, this proportion increased to 82 % (95 % confidence interval [CI] 74.0-88.2) for HIV, and 81 % (95 % CI: 73.0–87.0) for syphilis in the intervention city. Relative to baseline in the control city, the proportion testing for HIV was unchanged (52 %) but decreased for syphilis (26 %). Conclusions Bi-monthly text message reminders with weekly peer education sessions increased uptake of 3-monthly syphilis and HIV testing in a Ugandan female sex work population and could help increase sex worker engagement in HIV/STI services in line with World Health Organization recommendations.

Introduction Pre‐exposure prophylaxis (PrEP) to prevent HIV infection is being rolled out in Africa. The uptake of PrEP to date has varied across populations and locations. We seek to understand the drivers of demand for PrEP through analysis of qualitative data collected in conjunction with a PrEP demonstration project involving East African HIV serodiscordant couples. Our goal was to inform demand creation by understanding what PrEP means – beyond HIV prevention – for the lives of users. Methods The Partners Demonstration Project evaluated an integrated strategy of PrEP and antiretroviral therapy (ART) delivery in which time‐limited PrEP served as a “bridge” to long‐term ART. Uninfected partners in HIV serodiscordant couples were offered PrEP at baseline and encouraged to discontinue once infected partners had taken ART for six months. We conducted 274 open‐ended interviews with 93 couples at two Ugandan research sites. Interviews took place one month after enrolment and at later points in the follow‐up period. Topics included are as follows: (1) discovery of serodiscordance; (2) decisions to accept/decline PrEP and/or ART; (3) PrEP and ART initiation; (4) experiences of using PrEP and ART; (5) PrEP discontinuation; (6) impact of PrEP and ART on the partnered relationship. Interviews were audio‐recorded and transcribed. We used an inductive, content analytic approach to characterize meanings of PrEP stemming from its effectiveness for HIV prevention. Relevant content was represented as descriptive categories. Results Discovery of HIV serodiscordance resulted in fear of HIV transmission for couples, which led to loss of sexual intimacy in committed relationships, and to abandonment of plans for children. As a result, partners became alienated from each other. PrEP countered the threat to the relationship by reducing fear and reinstating hopes of having children together. Condom use worked against the re‐establishment of intimacy and closeness. By increasing couples’ sense of protection against HIV infection and raising the prospect of a return to “live sex” (sex without condoms), PrEP was perceived by couples as solving the problem of serodiscordance and preserving committed relationships. Conclusions The most effective demand creation strategies for PrEP may be those that address the everyday life priorities of potential users in addition to HIV prevention. Clinical Trial Number NCT02775929