Activity Narrative

Progress to-date, activities and achievements:

In COP 2008, FHI is receiving funding to generate strategic information on the extent and pattern of

concurrency in sexual partnerships, ad factors that may contribute to each. Specifically, the FY 2008

assessment will improve knowledge of partnership dynamics, their relationship to sexually transmitted

infection (STI), including HIV, risk and the factors that assist individuals in choosing and navigating

relationships in ways that reduce risk.

FY 2009 Activity: Assessment to Improve Understanding of Multiple Concurrent Sexual Partnerships and

Identify Potential Behavior Change Communication Strategies for Reducing Concurrency

In FY 2009, Family Health International (FHI) will build on the FY 2008 formative assessment to better

understand and describe multiple concurrent partnerships and identify potential behavior change

communication strategies for reducing concurrent partnerships. Additionally, FHI will focus on

understanding patterns of concurrency among populations identified as most at risk for HIV in the Ugandan

context.

Background

Multiple sexual relationships, outside of established couples, increase the risk of exposure to disease,

including HIV. In the last 10 years, concurrency of sexual partnerships has been proposed by several

authors as playing the more critical role in the dynamics of HIV epidemics. For the same number of sexual

partners, overlapping partnerships would be associated with a more rapid spread of HIV than serial

partnerships. Results from modeling exercises suggest that sexual concurrency increases both the intensity

and the variability of the intensity of an HIV epidemic and that the final size of the epidemic increases

exponentially as concurrency increases.

Concurrency in sexual networks has been proposed as a factor associated with the spread of HIV infection

in Uganda. For example, sexual networking data from rural Uganda suggests that sexual concurrency is

common among rural Ugandan adolescents, with males reporting higher rates of concurrent sexual

relationships than females. There is little information, however, to help us understand these patterns and

behavior change programs to prevent HIV have mainly promoted condom use or abstinence, while partner

reduction remains a largely neglected component of ABC.

In FY 2009, FHI will continue to improve knowledge about the type and extent of multiple concurrent

partnerships in Uganda and the underlying and contributing factors to these relationships. In FY 2009, FHI

will collect additional qualitative information to understand concurrency among most-at-risk populations

(MARPs), such as market vendors, truckers, commercial sex workers and fishing communities. Members of

these professions interact with each other, with their own spouses/partners, and with members of the

general population. This makes for situation in which risk of transmitting and acquiring HIV is heightened.

The aim of this mainly qualitative assessment will be to identify networks of sexual activity, risky behaviors

the different categories of MARPS commonly engage in; reasons why those risky behaviors are prevalent;

and to suggest possible BCC interventions that could be implemented to address these behaviors. Cluster

sampling will be applied to facilitate analysis by category of MARP. However, correlates of risk-behavior

patterns that cut across all categories of MARP will be highlighted. This exercise will generate valuable

qualitative data to complement the bio-behavioral surveillance USG has been conducting to measure HIV

risk behaviors, and determine prevention, care and treatment needs among MARPS in Uganda.

Additionally, in-depth analysis of sexual concurrence data generated through FY 2008 and 2009 will be

undertaken in order to identify behavioral patterns that could be addressed through behavior change

communication (BCC) interventions. Findings of this analysis and suggestions for potential BCC strategies

for reducing multiple concurrent partnerships will be disseminated widely to inform HIV prevention programs

in Uganda.

Expected Results

The assessment will provide strategic information to inform the implementation of sexual prevention

programs that focus upon high risk populations, including development of behavioral change interventions

targeting MARPs and other sexually active individuals in Uganda and the region.

New/Continuing Activity: Continuing Activity

Continuing Activity: 19069

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

19069 19069.08 U.S. Agency for Family Health 6735 5033.08 Contraceptive $247,815

International International and

Development Reproductive

Health

Technologies

and Utilization

(CRTU)

Table 3.3.02:

Activity Narrative, revised -

The Uganda PEPFAR team proposes to conduct an assessment of adverse events (AE) among traditional

circumcisers to empirically demonstrate dangers of the practice and to understand high HIV prevalence

among ethnic groups that rely on traditional male circumcision (TMC).

Almost 75% of men in Uganda are uncircumcised. Among those who are circumcised, an estimated 90%

are circumcised by traditional circumcisers. The overall goal of the Ministry of Health (MOH) in Uganda,

supported by PEPFAR and other development partners, is to scale up the provision and uptake of male

circumcision by medically trained providers, following UNAIDS / WHO recommendations. Studies from

Bungoma in Kenya show that TMC results in higher AE rates than MMCs. Should this assessment

demonstrate similar findings, the evidence will be provided to advance strategies that promote MC by

medically trained providers.

Additionally, there is skepticism among Ugandans regarding the effectiveness of male circumcision for HIV

prevention. Skeptics argue that communities which have practiced circumcision for generations also have

high HIV prevalence rates, like the non circumcised. The aim of the proposed assessment is to use

ethnographic approaches to document the nature of TMC and contrast it with the surgical guidance

provided by the WHO, to explain why TMC - as opposed to MMC - will not impact HIV prevention.

At a recently held meeting with the MMC task force of the MOH, terms of reference were outlined, including

surveillance. Based on the meeting, the Ministry of Health declared its intention to institute ongoing

surveillance. The results of the proposed assessment will inform the surveillance, and data generated will

be used by the MoH and partners to advocate for MMC as a safe and effective prevention tool to be added

within the current prevention approaches advocated in Uganda.

The assessment and related sample size will be designed and calculated in a way to answer the objectives,

and appropriate formulae to compute sample size for this kind of design will be applied. It is anticipated that

the minimum sample size for men who have undergone circumcision will be 216 for each of two districts,

giving a total sample size of 432. For the directly observed circumcisions, a minimum of 20 operations will

be observed. The assessment will also include a qualitative piece: FGDs and in-depth interviews will be

held with men, women, traditional circumcisers, and community opinion leaders. Typical to qualitative

methods, interviews will be held until saturation is achieved, which is expected at approximately 6-8 in depth

interviews for each category per district and approximately 3 FGDs of 6-8 participants per category per

district.

The system for management of identified AEs will be well outlined in the protocol. The teams will include

medically trained physicians / clinical officers with clinical training in MC procedures to help assess AEs and

advise on referral and / or on site management. Participants with identified AEs requiring clinical care will be

referred for specialized care if they cannot be managed by the assessment team. In cases of very severe

AEs requiring hospitalization, the team will facilitate a transfer of participants to hospitals. An agreement

with the District Health Office and the District Hospital will be reached to ensure that study participants who

may require medical attention get quality care promptly.

In addition to the strategy for clinical management of AEs, outlined above, the study will be conducted in

collaboration with the District Health Office (DHO) which is responsible for supervision of TMCs. Periodic

reports will be provided to the DHO and any information on AEs, with recommendations from the study

team will be transmitted to them to address during training and supervision.

It is expected that at least three attributes of TMCs may render them unsuitable for HIV prevention. They

include 1) Nature of the cut - an inadequate amount of the foreskin may be removed; and lack of

apposition of cut edges leaves a large surface area susceptible to entry of HIV (Brown, 2002); 2) There is

often an early resumption of sexual intercourse before certified wound healing; 3) The cultural rites that

accompany the circumcision which may include excessive alcohol consumption and sexual liberty, which

may in turn lead initiates into unprotected sexual activity prior to the circumcision and/or prior to wound

healing; 4) Intra-circumcision practices like use of same gloves, same knife, etc. that can increase the

likelihood of infection

Different methodologies will be used to document these dimensions. First, through direct observations of

circumcisions, the nature of the cut and intra-circumcision practices will be observed and contrasted with

the WHO-established surgical guidelines. Secondly, through observation and interviews with initiates and

community leaders and members, the processes immediately before circumcision and during the post -

operative period will be documented to bolster arguments about the inherently unsafe nature of the TMC

rites. It is anticipated that cultural issues might arise, as findings from the AE assessment are shared.

However experience from Kenya (FHI and others) suggests that engaging in a medical dialogue, versus a

cultural one, can advance local support for safe and voluntary MC. The support of the MOH and THETA,

an association of Ugandan traditional healers, in conducting this assessment will go a long way in ensuring

buy-in from the various political and cultural leaders in Uganda.

Although the results of this assessment are critical, they are not essential to begin working with TMCs,

except in the context of reducing the impact of complications and improving post operative management of

severe AEs, as recommended by Bailey et al in their 2006 study in Bungoma. The intention in this

assessment is to understand and describe why TMC does not lead to HIV reduction rather than to begin

employing traditional circumcisers to scale up circumcision. Another assessment approved in the COP

FY2008 is exploring the complementary roles (e.g. counseling, referral, post operative care) that TMCs can

be encouraged to play in supporting MMC interventions. Both assessments abide by the UNAIDS/WHO

recommendation for culturally sensitive services and procedures offered by trained providers. Results of

both assessments may allow a determination of the extent to which initiates may be willing to undergo MMC

instead of TMC, or whether they see a promising combination of both (eg the ceremonial part remains

traditional whereas the actual incision is performed by a medically trained provider). It is however important

to note that It may be difficult for the initiates to know the difference between MMC and TMC. Also since

data collection will be soon after the TMC procedure, there may be a risk of having responses that are

biased by the pain and discomfort the participants will still be enduring.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14191

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

14191 9097.08 U.S. Agency for Family Health 6735 5033.08 Contraceptive $300,000

International International and

Development Reproductive

Health

Technologies

and Utilization

(CRTU)

9097 9097.07 U.S. Agency for Family Health 5033 5033.07 Contraceptive $300,000

International International and

Development Reproductive

Health

Technologies

and Utilization

(CRTU)

Table 3.3.07: