Understanding the Contribution of Concurrent Sexual Relationships to the HVI Epidemic

Rationale: The 2006 UDHS found that 36% of married women were in polygamous marriages an indicator

for concurrent relationships. In the same survey, 28% of men reported having had sex with two or more

partners in the preceding 12 months. The spread of sexually transmitted infections (STIs), including HIV, is

much more rapid under conditions of concurrent partnerships. The pattern of concurrency, the duration of

overlap, and the frequency of sexual relations with each partner, also have significant implications for the

spread of the epidemic. The high rates of concurrent relations suggested by the DHS needs to be

addressed as part of the prevention strategy for HIV in the country.

Objectives: This formative assessment will generate strategic information on factors that contribute to the

extent and pattern of concurrency in sexual partnerships. In addition, a formative assessment will examine

the ways in which legal, religious, or other institutional factors facilitate or inhibit the formation, maintenance,

and the ending of sexual relationships, and the prevalence of concurrency.

Design: A randomized, cross sectional population based survey is planned. Both quantitative and

qualitative methods including in-depth interviews and/or some focus groups will be used in this assessment.

Setting: (location: community, facility, etc.)

This will be a community based survey. The communities to be included in the survey will be selected using

results from the UDHS to ensure that there is representation of communities where concurrent relationships

are likely to be encountered. Participants: (In/exclusion criteria, sample size)

At the community level women and men 15-49 will be interviewed about their sexual relationships and

factors influencing the formation and sustenance of the relationships. The sample size will be determined to

allow for comparison of responses by age, sex, and socio economic status.

Methods: Study variables will include explanatory factors including individual-level variables (biological,

psychological, demographic, and socioeconomic); partnership-specific characteristics; and social, cultural,

and economic characteristics. The latter may include such factors as family influences, social networks,

characteristics of "sexual market places," community norms, cultural expectations such as bride wealth or

dowry, job and housing markets, and public policies.

Outcomes: The strategic information generated through this formative assessment will contribute to the

development of enhance STI and HIV-prevention interventions, particularly among most-at-risk populations

(MARPS). Lessons learned will inform ongoing activities through the Regional Outreach Addressing AIDS

through Development Strategies (ROADS) project and HIV prevention programming with MARPS along

high prevalence transport corridors in Uganda.

Timeline: (Total time of data collection) 1 year

The introduction of male circumcision (MC) as an HIV prevention measure requires that safety be

paramount. Working with traditional practitioners to integrate them into a comprehensive MC rollout and

scale up strategy leverages an established healthcare delivery system, particularly for rural Ugandans.

Family Health International (FHI) will partner with the Traditional and Modern Health Practitioners Together

Against AIDS (THETA), a local NGO which aims to improve the health of rural Ugandans by involving

traditional health practitioners through training in health education, counseling, and in community support

initiatives. FHI will work with THETA to develop and implement strategies for leveraging traditional MC

practices as an opportunity to provide a more comprehensive package of HIV prevention interventions and

reproductive health messages. It is anticipated that results of this pilot intervention will inform policy

dialogue for male circumcision in Uganda.

Based on the results of three randomized trials in South Africa, Kenya and Uganda, the WHO and UNAIDS

have issued a set of recommendations for the use of male circumcision in HIV prevention efforts. The

document concludes that the evidence that male circumcision reduces the sexual transmission of HIV from

women to men by 60% is compelling enough to recommend it as an efficacious intervention for HIV

prevention (WHO/UNAIDS, 2007) The document also recommends that programs be implemented in

populations where the prevalence of heterosexually transmitted HIV infection is high and male circumcision

rates are low. The HIV and MC situation in Uganda is precisely as described in the WHO/UNAIDS

recommendations.

In Uganda, traditional circumcisers play an important role as healers and opinion leaders. However,

traditional circumcisers may lack formal, medicalized training, may perform circumcisions in an un-sterile

environment, and may even increase the risk of blood-to-blood transmission of HIV by using the same

instrument for more than one young man during MC ceremonies. Despite medicalized training, A 1999

study in Uganda found that 90% of study participants were circumcised by traditional or religious ‘surgeons'

and only 10% had the procedure in a hospital or clinic. Given the severe shortage of trained medical

personnel and the apparent acceptance of traditional MC in Uganda, there are challenging ethical dilemmas

in not integrating traditional practitioners into a coordinated and comprehensive response. Because of the

insufficient health care services in rural communities, traditional circumcisers may need to be included in

training opportunities to promote HIV prevention through appropriate risk reduction counseling, referrals and

linkages to clinic-based MC procedures, mainly.

Despite the urgent need to provide safe, voluntary MC to those most at risk, significant challenges remain.

First, there is no unified training curriculum or surgical guidelines for those providing traditional MC

procedures. In the absence of a national standard, misunderstandings and mistrust may arise from

Western-trained physicians. One thing is clear - there is no integration of clinic-based and traditional MC

services in Uganda. Thus, the second challenge, little communication between the two healthcare delivery

systems, must be understood to develop an effective referral and counter-referral system. Third, traditional

practitioners may be the only provider in rural areas, and are often well respected members of society.

Their role as opinion leaders is critical in ensuring correct information and proper counseling are available to

their clients and communities. The critical issue of proper wound healing, for instance, is a major challenge

that traditional circumcisers might be well placed to address and reinforce. Finally, policy makers must

consider the safety and efficacy of traditional MC in determining their possible role in a national MC

strategy.

Although little quantitative data on rates of complications from traditional circumcision in sub-Saharan Africa

exist, both scientific literature and media accounts document cases of advanced infection, stenosis,

necrosis, mutilation, and hemorrhage due to MC conducted by traditional practitioners. Working with

traditional practitioners to improve their knowledge and skills could greatly contribute to improved MC

outcomes as well as improving perceptions of MC as a safe procedure. FHI proposes to partner with the

THETA, to implement an intervention aimed at enhancing the capacity of traditional practitioners to support

safe circumcision, by providing information on safety, putting in place referrals links with clinical sites and

providers.

The activities will address both strategic information and programmatic needs. The combined approach will

provide decision makers with Uganda-specific data to inform a comprehensive MC strategy. The activities

will also facilitate more immediate improvements in HIV risk reduction and counseling by traditional

providers. Activities will be conducted in a phased approach with year one (Phase I) focusing on

documenting what is known about the capacity, scope, and outcomes of traditional circumcisers in Uganda.

Efforts in future years will build on the Phase I data and partnerships to operationalize and evaluate a

referral system and a skills/cultural exchange between traditional and clinic-based circumcisers.

The proposed Phase I activities are as follows:

1.Conduct a census of traditional circumcisers to determine their numbers, activity level, and location.

2.Conduct an assessment to determine the training needs of traditional circumcisers with regard to safety,

hygiene, and counseling.

3.Conduct a rapid assessment to explore the bi-directional assumptions and attitudes between traditional

and clinic-based providers, which will be useful for recommending a referral system.

4.Provide technical assistance to THETA and partners to support information and training for traditional

providers of MC, focusing on counseling, safety/hygiene, and risk reduction for men, both pre and post

operatively. The aim is to utilize MC as a vehicle to reach more men with SRH and HIV prevention

messages.

5.Develop and launch a pilot surveillance system to capture MC adverse events.

6.Compare rates of adverse outcomes between traditional and clinic-based circumcisers and synthesize

findings for policy dialogue and programmatic uptake.

This PEPFAR funded activity will generate strategic information on the potential role of traditional providers

in a wide scale male circumcision intervention. The knowledge generated will be translated into practical

applications in planning, policy making, program administration, and the support for quality, accessible male

circumcision services. Further, the activity will provide an important avenue for reaching more men and

adolescent boys with other reproductive health messages and HIV prevention interventions e.g. sexuality

counseling.