Uganda AIDS Commission

Transcription

1 ` Uganda AIDS Commission Uganda HIV/AIDS Control Project (MAP) LQAS Monitoring Report Assessment of HIV/AIDS Related Knowledge, Practices and Coverage in 19 Districts of Uganda October-November 2003 Phyllis Joy Mukaire David Kaweesa Kisitu John B. Ssekamatte-Ssebuliba Joseph J. Valadez June 2004

2 Table of Contents LIST OF ACRONYMS...V ACKNOWLEDGEMENTS... VI EXECUTIVE SUMMARY...1 MAJOR FINDINGS...1 FOLLOW-UP STUDY RESULTS...3 CHAPTER 7 REPORTS FINDINGS OF THE DIAGNOSTIC STUDY WHICH MANAGERS SHOULD CONSIDER WHEN DESIGNING STRATEGIES FOR IMPROVING OR REDIRECTING THEIR PROGRAMS.BACKGROUND...3 BACKGROUND...4 THE MULTI-COUNTRY AIDS PROJECT...4 DISTRICT VARIATIONS...5 CHAPTER 1: FINDINGS FOR MEN VOLUNTARY COUNSELING AND TESTING...6 KNOWLEDGE OF MOTHER-TO-CHILD TRANSMISSION OF HIV/AIDS...7 KNOWLEDGE OF THE ABC S OF HIV/AIDS PREVENTION AND KNOWLEDGE OF TREATMENT FOR STI S...8 MISCONCEPTIONS ABOUT HIV/AIDS...10 SELF-ASSESSMENT OF RISK...11 CONDOM USE...12 CHAPTER 2: FINDINGS FOR WOMEN VOLUNTARY COUNSELING AND TESTING...13 KNOWLEDGE OF MOTHER-TO-CHILD TRANSMISSION OF HIV/AIDS...14 KNOWLEDGE OF THE ABC S OF HIV/AIDS PREVENTION AND KNOWLEDGE OF TREATMENT FOR STIS...14 MISCONCEPTIONS ABOUT HIV/AIDS...15 SELF-ASSESSMENT OF RISK...16 CONDOM USE...17 CHAPTER 3: FINDINGS FOR MOTHERS OF CHILDREN KNOWLEDGE OF MOTHER-TO-CHILD TRANSMISSION OF HIV/AIDS...19 USE OF ANTENATAL CARE SERVICES...19 DELIVERY IN A HEALTH FACILITY...20 COUNSELING ON MTCT AND VCT...21 CHAPTER 4: FINDINGS FOR YOUNG PEOPLE KNOWLEDGE OF THE ABC S OF AIDS PREVENTION...22 SEXUAL BEHAVIOUR...23 CORRECT USE OF CONDOMS...25 SELF-ASSESSMENT OF RISK AND MISCONCEPTIONS ABOUT TRANSMISSION...26 KNOWLEDGE OF SEXUALLY TRANSMITTED INFECTIONS AND OF MTCT...27 LQAS Report October-November 2003 page ii

3 CHAPTER 5: FINDINGS FOR ORPHANS TYPES OF ORPHANS...29 EDUCATION...30 CARE AND SUPPORT...32 MATERIAL SUPPORT...32 CHAPTER 6: FINDINGS FOR PEOPLE LIVING WITH HIV/AIDS...33 A PROFILE OF PLWHAS...33 MEDICAL CARE FOR PLWHAS...34 OTHER TYPES OF CARE AND SUPPORT...35 POSITIVE LIVING PRACTICES...36 HARMFUL PRACTICES...37 MISCONCEPTIONS ABOUT HIV/AIDS...38 KNOWLEDGE OF THE ABCS OF HIV/AIDS PREVENTION AND CONDOM USE...38 CHAPTER 7: FINDINGS OF THE FOLLOW-UP STUDY...40 PURPOSE OF THE FOLLOW-UP STUDY...40 FINDINGS...41 Preventing MTCT...41 PMTCT Facility Assessment...45 TYPE AND LEVEL OF FACILITY...46 CONDOM USE...49 VOLUNTARY COUNSELING AND TESTING...56 PEOPLE LIVING WITH HIV/AIDS...61 PLWHA Service Facility Assessment...64 ORPHAN CARE AND SUPPORT...67 COMMUNITY LEVEL HIV/AIDS EDUCATION AND PROMOTION...68 METHODS...70 Study Area...70 Capacity to Undertake the Study...70 Study Methods and Target Groups...70 Facility Assessment...71 Key Informant Interviews...71 Focus Group Discussions...71 Document Review...72 CHAPTER 8: LQAS PRINCIPLE AND METHOD...73 PRINCIPLES...73 METHODS...75 The Sample...75 Sampling at the District Level...75 SELECTING AND TRAINING INTERVIEWERS...76 Training...77 DATA COLLECTION...77 DATA ANALYSIS...80 OVERVIEW OF LQAS IMPLEMENTATION...80 LQAS Report October-November 2003 page iii

4 ANNEX 1: LQAS PRINCIPLES FOR PROGRAMME MONITORING...81 APPENDICES...84 APPENDIX A. KEY MEN S INDICATORS BY DISTRICT...84 APPENDIX B. KEY WOMEN S INDICATORS BY DISTRICT...91 APPENDIX C. KEY MOTHERS INDICATORS BY DISTRICT...96 APPENDIX D. KEY YOUNG PEOPLE DISTRICT INDICATORS APPENDIX E. KEY ORPHANS INDICATORS BY DISTRICT APPENDIX F. KEY PLWHA INDICATORS BY DISTRICT REFERENCES LQAS Report October-November 2003 page iv

5 List of Acronyms ABC AIDS ANC ART CHAI CSO DHAC HIV IGA IEC GAMET LQAS M&E MAP MIS MTCT NGO NSF OVC PCT PLWHA PMTCT STD TASO TRN UAC UACP UNGASS VCT Abstinence, Be Faithful, Condom Use Acquired imuno-deficiency syndrome Antenatal Care Antiretroviral Treatment Community HIV/AIDS Initiative Civil Society Organization District HIV/AIDS Committee Human Imuno-Deficiency Virus income-generating activities information, education, and counseling Global AIDS Monitoring and Evaluation Support Team Lot Quality Assurance Sampling or Local Quality Assurance and Supervision monitoring and evaluation Multi-country AIDS Project management information system mother-to-child transmission nongovernmental organization National Strategic Framework orphans and vulnerable children project coordination team people living with HIV/AIDS prevention of mother-to-child transmission sexually transmitted disease The AIDS Support Organization technical regional network Uganda AIDS Commission Uganda AIDS Control Project United Nations General Assembly voluntary counseling and testing LQAS Report October-November 2003 page v

6 Acknowledgements The Uganda LQAS survey, implemented by the UAC in 19 districts, was the first of its kind in Uganda. The major objective of the LQAS survey was to build monitoring and evaluation capacity at the district and community levels and to assess the HIV/AIDS programme at those levels. The results of the survey have enabled local managers to not only know the current status of their programmes but also to make management decisions about how to improve them. Used regularly, LQAS will enable managers to continuously review and make management decisions to improve their programme strategies. At the same time the survey results will be used for national and global reporting. The UAC and management of the UACP would like to thank the many people were responsible for the successful completion of this effort. Special thanks to DHAC members, CSOs, and other implementers at the county level (under the leadership of the District HIV/AIDS Focal Persons in the 19 districts) for mobilising communities, collecting data, and hand-tabulating their respective district results. We thank the PLWHAs for their active participation in collecting and analysing data, and the local leaders, particularly those at the village level, who coordinated the data collection in their respective villages. Special gratitude also goes to all the respondents for investing their valuable time in this work. The TRN members provided valuable back-up support to UACP in planning and implementing the survey. The contribution of the following UACP Regional Project Officers was instrumental in the planning and implementation of the survey: Peter Cwinya-ai, Catherine Muwanga, Mayanja S.P, and Ssinabulya Mwanje. In addition, the IEC Specialist Lillian Nakato and the CHIA Specialist Steven Kiirya contributed greatly to the success of the survey. Special thanks go to the MIS officer, Charles Nkolo, who in addition to helping plan and implement the survey also coordinated and managed the data entry. The Project Management also provided valuable technical support and guidance, and the administrative and support staff at UACP and in the districts worked especially hard. We also acknowledge the Uganda Bureau of Statistics for providing sampling frames and maps, the Institute of Statistics and Applied Economics at Makerere University for providing technical and expert advice to the survey team, the Uganda Community Based Care Health Association for generating the household lists, and the AIM and UPHOLD projects for their partnership in implementing the survey. The UAC is likewise grateful for the support of the Ministry of Health for their expert advice on programme indicators and on the survey design. The UAC technical team also provided valuable support and guidance. The technical support provided by the Global AIDS Monitoring and Evaluation Support Team (GAMET) of The World Bank was critical in undertaking the survey. GAMET s technical support has contributed greatly to building the capacity for monitoring and evaluating HIV/AIDS activities in the country and is very much appreciated. At The World Bank, Shiyan Chou, Son Nam Nguyen. Peter Okwero, Susan Stout, and Yoko Shimada played essential roles in this activity. The Uganda AIDS Control Project, July 2004 LQAS Report October-November 2003 page vi

7 Executive Summary Reducing the prevalence of HIV/AIDS is an urgent priority for the government of Uganda and is defined in the National Strategic Framework (NSF) 200/1 2005/6. The leading programme in the fight against HIV/AIDS is the Multi-country AIDS Project (MAP), a set of interventions funded by The World Bank. MAP was designed to support the operationalization of the NSF specifically meant to scale up the national response. In early 2004, the MAP initiative in Uganda will undergo a mid-term review, and in preparation for that review the Uganda AIDS Control Project (which implements MAP) has conducted an assessment of the initiative in 19 districts (listed in the Appendices), with the help of the World Bank s Global AIDS Monitoring and Evaluation Support Team (GAMET). The assessment measured: The knowledge and perceptions of men 15-54, women 15-49, and youth of: o HIV/AIDS o Sexually transmitted disease prevention o The role of voluntary counseling and testing (VCT) in HIV/AIDS prevention o Preventing mother-to-child transmission of HIV/AIDS o HIV/AIDS-related services in their community PMTCT and STD practices among mothers of children 0-11 months HIV/AIDS prevention practices among men, women, and youth The adequacy of care and support services for orphans (6-18 years), and for people living with HIV/AIDS (PLWHAs). Major Findings The major findings of this assessment will be used by district programme staff to evaluate the impact of their efforts to date and make appropriate changes to their strategies, priorities, and allocations of resources. A selection of the findings for each group is presented below, along with brief commentary. Percentage decimals have been rounded. Please note that these results should not be compared with the results of the 2001 Uganda DHS. The principal reasons for this are that: (1) this study includes only 19 districts whereas the DHS includes all districts; and (2) the age ranges of some of the populations differ (e.g., mothers of infants 0-11 months in this survey as opposed to mothers of children under 5 years of age in the DHS survey).. Men Years Men who knew at least two of the benefits of VCT: Men who had taken an HIV test: Men who knew of the risk of MTCT: Men who had sex with a non-regular partner in the last 12 months: Men who had ever used a condom: 47 per cent 14 per cent 80 per cent 24 per cent 51 per cent LQAS Report October-November 2003 page 1 of 117

8 A striking conclusion from the findings among men is an apparent disconnect between knowledge and behaviour. While nearly half of men (47 per cent) knew at least two of the benefits of voluntary counseling and testing, only 14 per cent had actually taken an HIV test. In a similar finding, 64 per cent knew two or more of the ABCs of prevention but just over half of men (51 per cent) said they had ever used a condom. The disconnect aside, it should be a matter of some concern that 86 per cent of the men in Uganda have apparently not had an HIV test and that half the men have never used a condom. Women Years Women who knew at least two of the benefits of VCT: Women who had taken an HIV test: Women who knew of the risk of MTCT: Women who had sex with a non-regular partner in the last 12 months: Women who had ever used a condom: 39 per cent 14 per cent 78 per cent 9 per cent 31 per cent Women were also much more likely to be aware of the benefits of VCT (39 per cent) than to have acted on this information and actually taken a test (14 per cent). Women were almost three times less likely than men to have had casual sex (sex with a non-regular partner in the last 12 months), but they were also less likely to have used a condom during sex (31% per cent. More women than men may be having unprotected sex, a risk factor for HIV/AIDS, but fewer are having casual sex (another risk factor). Four fifths of all men and women knew the risk of MTCT. Mothers of Children 0-11 Months Mothers who attended an antenatal care clinic: Mothers who knew the risk of MTCT: Mothers who were counseled to take an HIV test: Mothers who took an HIV test: Mothers who delivered in a health facility: Mothers who delivered at home: 80 per cent 81 per cent 38 per cent 13 per cent 51 per cent 49 per cent Mothers were well aware of the risk of MTCT. It is disappointing that just over one third of mothers were counseled about HIV and only 13% (the same per cent as men) had taken a test. ANC centres appear to be missing an opportunity to counsel women about VCT. Nearly half of mothers delivered in a health facility, which usually reduces the risk of MTCT during labour and delivery. Young People Years Young people who knew at least two of the ABCs: Median age of first sexual intercourse: Young people who always use a condom: Young people who know how to use a condom correctly: 52 per cent 17 years 26 per cent 30 per cent Young people appear to be taking risks in their sexual behaviour, in spite of more than half knowing at least two of the ways to protect themselves. LQAS Report October-November 2003 page 2 of 117

9 Orphans 6-18 Years Orphans in school: Orphans in school who attended 5 days of class in the preceding week: Receiving support: Educational Psychosocial Material 82 per cent 71.6 per cent 15 per cent 10 per cent 3 per cent It is encouraging that four fifths of orphans are in school, and that 73 per cent of school attendees went to school five days in the week preceding the survey. However, only a small percentage of orphans are getting any kind of support. People Living with HIV/AIDS PLWHAs who received medical care if needed: PLWHAs who joined a support organization/group: PLWHAs who always use a condom: Sexually active PLWHA who never use a condom: Condom use by gender: Men who always use Women who always use 94 per cent 68 per cent 49 per cent 23 per cent 33 per cent 67 per cent PLWHAs appear to have access to medical care. It is also encouraging that two thirds have joined a support group. Male condom use is low for people who should know the risk. Follow-up Study Results The assessment raised as many questions as it answered, especially in the area of the breakdown between what people knew about HIV/AIDS and its risks and their own sexual behaviour. A follow-up study section (chapter 7) addresses some of the more urgent questions, specifically: readiness of locations or sites designated to provide PMTCT reasons behind the low use of condoms among women and young people what motivates women, men and young people to use VCT and what are the impediments why only a few orphans are reached in those districts where orphan care and support interventions have been tried why PLWHAs do not embrace safer sex practices despite exposure to positive living counseling Chapter 7 reports findings of the diagnostic study which managers should consider when designing strategies for improving or redirecting their programs. LQAS Report October-November 2003 page 3 of 117

10 Background Fighting the HIV/AIDS epidemic has become an urgent national priority for the government of Uganda and is in fact one of the key components of the national Poverty Eradication Action Plan. The goals of the national response to the AIDS epidemic, as set out in the National Strategic Framework for HIV/AIDS Activities in Uganda, are: 1. To reduce HIV prevalence by 25 per cent 2. To mitigate the effects of HIV/AIDS, specifically: To mitigate the health effects of HIV/AIDS and improve the quality of life of people living with AIDS To mitigate the psychosocial and economic effects of HIV/AIDS To mitigate the impact of HIV/AIDS on the development of Uganda 3. To strengthen the national capacity to coordinate and manage the multisectoral response to HIV/AIDS The Multi-Country AIDS Project One of the key initiatives in the fight against HIV/AIDS is the Multi-country AIDS Project (MAP) funded by The World Bank. The highly decentralized MAP approach focuses on community- and district-level efforts. In Uganda, the MAP initiative is being carried out by the Uganda AIDS Control Project or UACP (hereafter referred to as the Project in this report). In early 2004, the MAP initiative in Uganda will undergo a mid-term review, and in preparation for that review UACP, with the help of the World Bank s Global AIDS Monitoring and Evaluation Support Team (GAMET), has carried out an assessment of the Project in 19 districts. The overall purpose of the assessment was to determine the impact of the Project s efforts in certain key areas that are especially relevant to the three national HIV/AIDS goals listed above. Specifically, the assessment was designed: To assess the adequacy of care and support services for orphans To assess the adequacy of care and support services for PLWHAs To determine the knowledge and perception of men 15-54, women 15-49, and youth on HIV/AIDS To determine the knowledge and perception of men 15-54, women 15-49, and youth on STD prevention To determine the knowledge and perception of men 15-54, women 15-49, and youth on the role of VCT as an HIV/AIDS prevention option To determine the knowledge and perception of men 15-54, women 15-49, and youth on PMTCT To identify PMTCT practices among mothers of children 0-11 months To identify HIV/AIDS prevention practices among men, women, and youth To identify STD prevention practices among mothers of children 0-11 months LQAS Report October-November 2003 page 4 of 117

11 To assess awareness and knowledge of men 15-54, women 15-49, and youth about HIV/AIDS-related services available in their community For each of these 10 areas, a number of indicators were chosen to assess the current status. The indicators were derived from the goals of the National Strategic Framework described above, as well as from the monitoring and evaluation frameworks of other national HIV/AIDS programmes and UNGASS. In keeping with MAP s decentralized approach, the assessment was carried out in the 19 districts using a method known as Lot Quality Assurance Sampling (LQAS), a data collection and analysis technique designed to be used by field staff at the local level to assess the impact of their activities. (The philosophy and methodology of LQAS are described in chapter 8.) This report presents the major findings of the assessment, organized according to the six populations studied: Chapter 1: Findings for Men Chapter 2: Findings for Women Chapter 3: Findings for Mothers of Children 0-11 Chapter 4: Findings for Young People Chapter 5: Findings for Orphans 6-18 Chapter 6: Findings for People Living with HIV/AIDS Chapter 7: Findings of the Follow-Up Study Chapter 8: LQAS Philosophy and Methodology District Variations Readers are advised that the data presented in the tables in the main body of this report are averages for the 19 districts and do not necessarily tell the story for any one district. Indeed, in many cases the story in one district how well or poorly that district is performing on any particular indicator is very different from the story in other districts, and, therefore, very different from the data given in the tables. For that reason, programme managers, local staff, and other interested readers should always consult the relevant table in the Appendices which present survey results by individual district before reaching any conclusions about their activities. Readers are therefore advised that district specific result tables, which present survey results by individual counties, for all indicators assessed are available at the district HIV/AIDS coordination offices. LQAS Report October-November 2003 page 5 of 117

12 Chapter 1: Findings for Men Reducing HIV prevalence among men (as well as women) depends in part on what they know about the disease and prevention and on how they behave. For these reasons, the assessment sets out to establish how much men know about key variables that could influence their behaviour, as well as their knowledge of practices that increase the risk of exposure to HIV/AIDS. All results are weighted by the population size of the counties in which the sampling took place. Voluntary Counseling and Testing The NSF says that all programs in Uganda are supposed to publicize and promote the benefits of voluntary counseling and testing for HIV as a way of encouraging more men to get tested. The rationale behind this emphasis is that for men to undertake VCT they must clearly understand and be convinced of its benefits. The study, therefore, set out to determine how much knowledge there was among men about the benefits of VCT, using as an indicator the number of men who knew at least two of the benefits of VCT as promoted by the UACP programme. (These benefits are: to be able to plan one s future, to avoid reinfection if one is already positive, and to learn to live positively with HIV/AIDS.) As the results in Table 1.1 show, knowledge in this area is still low among men 15-54, with less than half being able to cite at least two benefits of VCT. It should be noted in this context that men of this age are most likely to be husbands of women in the reproductive age bracket, Given the male-dominated decision-making structure in Ugandan culture, the fact that men have such low knowledge of the value of VCT has implications for the possibility of their wives going for testing and even of staying HIV negative. Another reason to find out if men know the benefits of VCT is to help determine whether or not they will be likely to submit to an HIV test. As Table 1 shows, although nearly half of the men knew the benefits of VCT, only 14 per cent took the test. This would suggest that merely educating men about the benefits of VCT is not enough to make them take a test. Issues of access, availability and quality of information and services must be considered and addressed as necessary. Table 1.1: VCT and MTCT Knowledge and Practice among Men LQAS Survey, Uganda, Indicator % Reporting Confidence interval Men who know 2+ VCT benefits Men who took an HIV test Men who requested an HIV test Men knowing the risk of motherto-child transmission LQAS Report October-November 2003 page 6 of 117

13 Knowledge of Mother-to-Child Transmission of HIV/AIDS Another strategy to contain the spread of HIV is to reduce the incidence of paediatric AIDS, whereby the virus is passed to a child from his/her HIV-positive mother. If women are going to try to prevent mother-to-child transmission of AIDS (MTCT), they need the support of their husbands, and husbands are more likely to offer support if they know about the risks of MTCT. Table 1.1 shows that four out of five men are aware of this risk. Two other factors that may contribute to male support of preventing MTCT are for men to know: (1) the routes through which mother-to-child transmission takes place, and (2) that the risk of mother-to-child transmission can actually be reduced. Table 1.2 presents the three means of MTCT of HIV during pregnancy, during delivery, and through breastfeeding and male awareness of each. It is significant that while one third to two thirds of men know about at least one route of transmission, only six per cent knew of all three. The data presented here are for unprompted responses from men; men were asked whether or not HIV could be transmitted from mother to child, and if they said yes, they were asked to name the routes of transmission. While 70 per cent of men mentioned that HIV can be passed to the infant during delivery, only 40 per cent mentioned the risk during pregnancy. This might suggest that men would not support their wives in seeking help during the antenatal period. The fact that only one third of men knew about the risks of MTCT during breastfeeding would suggest that they might assume breastfeeding was safe for children. With regard to the second factor, Table 1.2 shows that many more men, 70 per cent, know that the risk of MTCT can be reduced. The challenge for programme staff will be to build on what men know, using it as an entry point for adding on what they do not know. Table 1.2: Knowledge of MTCT Transmission Routes and Risk Reduction among Men, LQAS Survey, Uganda, Indicator % Knowing Confidence interval Knowledge of transmission route/risk of reduction: Pregnancy Delivery Breastfeeding Percentage knowing all 3 routes of MTCT Knows that the MTCT risk can be reduced LQAS Report October-November 2003 page 7 of 117

14 Knowledge of the ABC s of HIV/AIDS Prevention and Knowledge of Treatment for STI s Another strategy to prevent the spread of HIV/AIDS is the well-known ABC approach, where A stands for abstinence, B stands for be faithful to your partner, and C stands for the consistent and correct use of condoms during sex. Accordingly, the study measured male knowledge of at least two of the three ABC s, and Table 1.3 below shows that just under two thirds of men knew two or more ABC s. A related strategy for AIDS prevention is the widespread treatment of sexually transmitted infections (STIs) in the general population. This strategy is based on the finding from several studies that the presence of an STI greatly increases the risk of HIV infection and transmission. Since effective treatment would depend in part on men being able to recognize the signs and symptoms of STIs, the study measured the number of men who know at least two signs or symptoms. Table 1.3 below shows that a little over half of the men surveyed could mention two or more signs/symptoms in men, suggesting that many men could go for a long period with an STI before seeking treatment, hence an elevated risk for HIV infection, and not be aware of it. Since HIV/AIDS in Uganda is spread mainly through sexual relations, male knowledge of the signs and symptoms of STIs in women is another important factor in prevention, especially in light of the fact that men tend to dominate sexual decision-making. In this connection, the study sought to find out what percentage of men could recognize STI signs and symptoms in women. As Table 1.3 shows, just over 40 per cent of men had this knowledge, meaning that the female partners of almost 60 per cent of the men in the study area could have STIs and an elevated risk if HIV infection and their male partner would not know it. Table 1.3: Men s Knowledge of ABC and STI Symptoms, LQAS Survey, Uganda, Knowledge Category % Knowing Confidence interval 2 + of Abstinence, Be faithful, Condom use Mentions abstinence Mentions being faithful Mentions using condoms STI symptoms in men STI symptoms in women Note: This table combines findings from Table A3 and A4 in Appendix A. The UACP programme also has an initiative to reduce the incidence of STIs among men, particularly urethritis. The study therefore sought to determine how common this condition was among men in the study area, if they sought treatment, and if they paid for treatment. This latter point is important because treatment in government health facilities ought to be free of charge. Male respondents were asked whether in the 12 months preceding the survey they had had a burning sensation on urination (which is considered to be urethritis) or a discharge from the penis. The results presented in Table 1.4 reveal that about one in five men reported having had urethritis, which is a high level of prevalence when contrasted 2001 DHS LQAS Report October-November 2003 page 8 of 117

15 result; 9 per cent of the sample reported having had a discharge from the penis in the 12 months preceding the survey. In cases where people have STIs, the national programme strategy has been to ensure that they get treatment. The indicator here is the percentage of men who sought treatment for the discharge or burning sensation during urination, which, as can be seen in Table 1.4, was 62 per cent. Although this is more than a majority, it is still a point of concern that more than one third (nearly 40 per cent) of men did not seek treatment for these conditions and could be transmitting their infection. It is also important to establish whether the men who seek treatment pay for it. As shown in Table 1.4, 72 per cent of men paid, a finding which suggests that either a good number of the men were receiving free services or that having to pay for services might have discouraged a number of men from accessing them, or some of both. While STI treatment in government ought to be free, 52 of 124 (42 per cent) men who sought treatment had to pay for the service. Table 1.4: Prevalence of Urethritis and Urethral Discharge among Men and Their Treatment Patterns, LQAS Survey, Uganda, % Confidence Condition Reporting interval Urethritis Urethral discharge Sought treatment for condition Paid for treatment Table 1. 4A: Cross Tabulation of the Location Where Men Who Sought Treatment Were Treated for Discharge from Their Penis or Burning during Urination by Whether They Paid for the Treatment, LQAS Survey, Uganda, Location where treated for discharge or burning during urination Government health facility Private health Paid for treatment of discharge or burning during urination YES NO Total facility Traditional healer Pharmacy Self-medication Other Total LQAS Report October-November 2003 page 9 of 117

16 Another important indicator of STI treatment is whether men seek treatment in places that can provide complete and reliable services. As Table 1.5 shows, 79 per cent of men in this study sought treatment from dependable sources, i.e., government and private health facilities. 3.8 per cent used traditional healers, 9.7 per cent engaged in self-medication, and 9.7 per cent sought treatment from a pharmacy. Table 1.5. Facility Type for Those Who Sought Treatment, LQAS Survey, Uganda, Government health facility Private health facility Type of Facility Traditional Pharmacy healer Selfmedication Other Men seeking treatment Misconceptions about HIV/AIDS In addition to the strategies mentioned above, the UAC also has a campaign to dispel misconceptions about how HIV is spread. This is an important component of a general campaign to educate the population and keep them from engaging in practices that would give them a false sense of protection. Respondents were asked whether HIV could be transmitted in the following ways, all of which are misconceptions: through mosquito bites, touching an infected person, sharing utensils with an infected person, and sharing toilets with an infected person. According to the data presented in Table 1.6, the most widely held misconception concerns mosquitoes, with 38 per cent of the men interviewed believing HIV could be transmitted in this way, followed by toilet seats (believed by 18 per cent). Just over half of all men, meanwhile, rejected all five of the most common misconceptions. These findings suggest that nearly half of those surveyed are likely to engage in some form of false fear, such as avoiding mosquito bites or not sharing utensils with people who are HIV positive the latter of which can accentuate stigma. Table 1.6: Percentage of Men who Reject Common Misconceptions on HIV Transmission, LQAS Survey, Uganda, Misconception % Rejecting Confidence interval Through mosquitoes Touching infected person Sharing utensils Sharing toilets Through witchcraft Rejecting all five LQAS Report October-November 2003 page 10 of 117

17 Self-Assessment of Risk One factor that makes a particular behaviour more or less likely is the perceived degree of risk. The study undertook to measure men s assessment of whether or not they believed they were at risk for getting HIV/AIDS, the reasons for their perceived degree of risk, and the validity of those reasons. Table 1.7 shows that a third of the men considered themselves to be at high risk of HIV infection. Table 1.7 also seems to suggest that a common assumption about HIV/AIDS that people who are better educated have a better understanding of the risks may not be accurate. Except for those with a post-secondary education, the table shows that there is virtually no variation across educational groups among those men who considered themselves at high risk. Table 1.7: HIV Risk Assessment among Men by Level of Education, LQAS Survey, Uganda, Risk assessment/education Perceive themselves at high risk % Reporting Confidence interval High risk by educational groups: None Primary Secondary Post-secondary The findings in Table 1.8, regarding the reasons why men believe themselves to be at high or low risk, show that men generally do not have an accurate assessment of high risk, with the exception of the low number (4.5 per cent) who consider themselves at high risk because they are unmarried. The most striking finding here by far is that only 16.3 per cent of men consider not using condoms as a high risk factor when not using a condom is in fact the single highest risk factor in the sexual transmission of AIDS. In the low or no risk category it is noteworthy that the most commonly cited reason here is that partners are faithful to each other. But in point of fact a married man (or woman) can only know if he/she is faithful; not being able to guarantee one s partner s faithfulness means that fidelity cannot on its own be considered a protection against risk. LQAS Report October-November 2003 page 11 of 117

18 Table 1.8: Men s Perceived Risk Assessment and their Reasons, LQAS Survey, Uganda, Respondents of this class of perceived risk who mentioned this reason % Reporting Confidence interval High risk: Not married No steady partner Do not use condoms Don t trust partner Many partners Most people infected Low or no risk: Not married Abstaining Married Faithful Use condoms Still a virgin Still young Condom Use With regard to risk, the Project strongly promotes condom use among all population groups, and the study asked men whether or not they had ever used a condom. As Table 1.9 shows, more than half of men had used a condom at least once. The study also set out to establish the prevalence of sexual relations with non-regular partners, another risk factor targeted by the national effort. Men were asked whether in the 12 months preceding the survey they had had sex with someone other than their wife or regular partner, and nearly one quarter reported that they had. As Table 1.9 shows, only 42 per cent of those who had sex with a non-regular partner reported using a condom during the last sexual contact with a non-regular partner, suggesting that casual sex in the study population is a big risk factor. Table 1.9: Sexual Behaviour and Condom Use among Men, LQAS Survey, Uganda, Behaviour % Reporting Confidence interval Ever used a condom Had sex with non-regular partner in 12 month period Used condom with nonregular partner LQAS Report October-November 2003 page 12 of 117

19 Chapter 2: Findings for Women The assessment of the Ugandan HIV/AIDS programme asked similar questions of and measured many of the same indicators for women as for men. As with men the overall goal was to understand how much women know about and what their behaviours are vis a vis HIV/AIDS so that UACP staff can decide where to target their resources, how well their efforts are succeeding, and where changes may need to be made. Voluntary Counseling and Testing As with men, a very important starting point for preventing the spread of HIV/AIDS is for women of reproductive age (15-49) to know their sero-status. Women should therefore be encouraged to get voluntary counseling and testing (VCT) for HIV. Since women are more likely to go for VCT if they understand and are convinced of its benefits, the study set out to establish the level of knowledge among women about the benefits. The indicator of this knowledge was the number of women who knew at least two of the benefits of VCT as promoted by the national campaign. As demonstrated in Table 2.1, knowledge in this area among women is still relatively low, just over one third. It is important to note here that these are women in the reproductive age group and thus at the highest risk of sexually transmitted HIV infection. One important reason to find out whether women know the benefits of VCT is the likelihood that if they know the benefits, then they will be more inclined to get tested for HIV. Table 2.1 shows that while almost 40 per cent of women know the benefits of VCT, only 14 per cent had taken the test. Clearly, awareness of the benefits by itself is not a sufficient condition to motivate women to be tested. Table 2.1: VCT and MTCT Knowledge and Practice among Women, LQAS Survey, Uganda, Indicator Women who know 2+ VCT benefits Women who requested an HIV test Women who took an HIV test Women knowing about risk of mother-to-child transmission % Reporting Confidence interval LQAS Report October-November 2003 page 13 of 117

20 Knowledge of Mother-to-Child Transmission of HIV/AIDS Another strategy to contain the spread of HIV is to reduce the incidence of paediatric AIDS or mother-to-child transmission (MTCT). It can be assumed that only women who know about the risk of MTCT are likely to participate in this strategy. As Table 2.1 demonstrates, knowledge of MTCT among women is 78 per cent. Merely knowing the risk of MTCT, however, is usually not by itself sufficient motivation for women to participate in this initiative. There are two other important conditions that may need to be met: (1) women must know the routes through which mother-to-child transmission takes place; and (2) women must know that the risk of mother-to-child transmission can actually be reduced. Table 2.2 shows that fewer than 10 per cent of the women surveyed knew all three routes of MTCT during pregnancy, during delivery, and post-partum through breastfeeding suggesting that at a minimum more education is needed before women will take preventive action against all three risks. With reference to the other condition, knowing that the risk can be reduced, Table 2.2 shows that just over half of women knew about this possibility. The other half, presumably, will not be motivated to take steps to reduce MTCT since they are not aware that it s possible. Once again, more education will be necessary. Table 2.2: Knowledge of MTCT Transmission Routes and Risk Reduction among Women, LQAS Survey, Uganda, Transmission Route/Risk Reduction % Knowing Confidence interval Pregnancy (unprompted) Delivery (unprompted) Breastfeeding (unprompted) Knowing all 3 routes of MTCT Know that the MTCT risk can be reduced Know that the MTCT risk can be reduced and also the 3 routes of transmission Knowledge of the ABC S of HIV/AIDS Prevention and Knowledge of Treatment for STIs Another focus of the Project in Uganda is to prevent the spread of HIV through sexual transmission in the general population. This effort makes use of the ABC strategy, where A stands for abstinence from sex, B stand for being faithful to one s sexual partner, and C stands for the consistent and correct use of condoms. The study sought to find out to what extent women had internalised the ABC messages, using as its indicator the per cent of women who know at least two of the three preventive measures promoted by the Project. Table 2.3 shows that less than half of women knew two or more of the three ABC practices. Another programme strategy is the widespread treatment of sexually transmitted infections (STIs) in the general population. This strategy is based on the finding from several studies LQAS Report October-November 2003 page 14 of 117

21 that the presence of an STI greatly increases one s risk of HIV infection. For women to seek treatment, they must first be able to recognize the symptoms of STIs, and accordingly the study set out to measure knowledge among women of the signs and symptoms of STIs. The indicator used here was the percentage of women who know at least two signs or symptoms. Table 2.3 shows that just over half of women could cite two or more STI signs and symptoms in themselves, meaning that nearly half of women could go for months with an STI, hence an elevated risk of HIV infection, without being aware of it or seeking treatment. Since HIV/AIDS in Uganda is spread mainly through sexual relations, women s knowledge of the signs and symptoms of STIs in men is another important factor in prevention. Women who had that kind of knowledge could help fight the spread of HIV either by refusing to have sex with a man who has those signs or by advising him to go for treatment, or both. In this regard, the results presented in Table 2.3 are disappointing, with only a third of women able to recognize the signs and symptoms of STIs in men. This means that the male partners of two thirds of the women in this study area could have STIs and an elevated risk of HIV infection or transmission and their female partner would not realize this. If these women then went ahead and had sex with these men, they could not only infect themselves with an STI, but they would also be putting themselves at an increased risk of getting HIV. Table 2.3: Women s Knowledge of ABC and STI Symptoms, LQAS Survey, Uganda, Knowledge Category % Knowing Confidence interval 2 + of Abstinence, Be faithful, Condom use Mentions abstinence Mentions being faithful Mentions using condoms STI symptoms in women STI symptoms in men Misconceptions about HIV/AIDS The Ugandan programme includes a campaign to dispel misconceptions about how the AIDS virus is spread. This is an important component of a campaign to educate the general population and keep them from engaging in practices that would give them a false sense of security or increase stigma of those who are HIV infected. A key Project indicator in this regard is the number of women who reject all of the five major misconceptions about HIV transmission. As Table 2.4 shows, just over 40 per cent of women rejected all five, leaving 60 per cent likely to engage in some form of false protection or fear, such as avoiding mosquito bites or not sharing toilets with people who are HIV positive. LQAS Report October-November 2003 page 15 of 117

22 Table 2.4. Percentage of Women Who Reject Common Misconceptions about HIV Transmission, LQAS Survey, Uganda, Misconception % Rejecting Confidence interval Through mosquitoes Touching infected person Sharing utensils Sharing toilets Through witchcraft Rejecting all five Self-Assessment of Risk In light of persistent misconceptions about how HIV is transmitted and the percentage of women who did not know signs of STIs or even two of the ABCs, the study undertook to measure whether or not women believed they were at risk for getting HIV/AIDS. Table 2.5 shows that 36 per cent of women considered themselves to be at high risk of HIV infection. Although this is a very high percentage by most standards, it is noteworthy and a cause for concern that this figure is 14 per cent lower than the 50 per cent of women who reported not knowing even two of the ABCs and who are, therefore, at considerable risk of getting HIV. It is interesting that the main reason women perceive themselves to be at high risk is that they do not trust their partners (nearly 60 per cent). However, 37.5 per cent say they either have no steady partner or several partners. Not being married is not associated with this risk level. Conversely, women who perceive themselves to be at low or no risk report as their reason that they are faithful to their partner or married. LQAS Report October-November 2003 page 16 of 117

23 Table 2.5. HIV Risk Assessment among Women, LQAS Survey, Uganda, Reason reported for having this perceived level of risk % Reporting Confidence interval Perceived High Risk Not married No steady partner Do not use condoms Don t trust partner Have many partners Most people are infected Perceived Low or No Risk Not married Abstaining Married Faithful to each other Using condoms Still a virgin Still young Table 2.6: HIV Risk Assessment among Women by Level of Education, LQAS Survey, Uganda, Highest level of schooling completed Percentage of women perceiving themselves at various levels of risk High Low No Don t Know Total None Primary Secondary Post-secondary Total Condom Use Condom use is yet another protection strategy promoted by the Project. The study therefore took particular interest in finding out what per cent of women had ever used a condom. The results, presented in Table 2.7, show that only about 30 per cent of women reported ever using a condom, a disturbingly low figure in light of the level of risk outlined above. On a related indicator, however, which is also another high risk factor for HIV, women were doing better (and doing much better than men). As Table 2.7 shows, only 9 per cent of women reported having sex with non-regular partners in the 12 months preceding the survey (as compared with just under 24 per cent of men). Asked whether they had used a condom during their last sexual contact with a non-regular partner, just over one third answered yes. LQAS Report October-November 2003 page 17 of 117

24 Clearly, casual sex is a very low risk factor in this study population, although those that engage in it are at very high risk because only 37.1 per cent use condoms. Table 2.7: Sexual Behaviour and Condom Use among Women, LQAS Survey, Uganda, Behaviour % Reporting Confidence interval Ever used a condom Had sex with non-regular partner in 12 month period Used condom in last contact with non-regular partner LQAS Report October-November 2003 page 18 of 117

25 Chapter 3: Findings for Mothers of Children 0-11 With regard to pregnant women, the main thrust of the UACP initiative has been preventing mother-to-child transmission of HIV/AIDS (MTCT). To get information about the knowledge, attitudes, and practices of pregnant women, the study interviewed mothers with children between 0 and 11 months of age at the time of the survey. This population was selected because of their relatively recent contact with the health system, making their observations more current. Knowledge of Mother-to-Child Transmission of HIV/AIDS If preventing MTCT is to be considered a viable goal, would-be mothers should be aware of the risk of mother-to-child transmission and the possibility of reducing that risk. Thus the study began by establishing whether mothers in the target group knew about the risk of MTCT, and, as Table 3.1 shows, more than 80 per cent of mothers did. Despite this high level of knowledge, however, only about half of those surveyed knew that this risk of MTCT could be reduced. Table 3.1: Mothers Knowledge about the Risk of Mother-to-Child Transmission of HIV, LQAS Survey, Uganda, Indicator % Reporting Confidence interval Knows about mother-to-child transmission Knows risk of MTCT can be reduced Use of Antenatal Care Services Another key variable in preventing MTCT is the use of antenatal care (ANC) services, as this is where most mothers first learn about MTCT and are recruited into the prevention programme. Mothers were asked, therefore, whether they had attended ANC for their index pregnancy. Table 3.2 shows that the overwhelming majority (92 per cent) of mothers had attended ANC, which suggests that most women had at least the potential to be exposed to MTCT education and counseling. For MTCT prevention to actually work, mothers should adhere to certain procedures set up by ANC facilities. These include making the required minimal number of antenatal care visits (a total of four) as well as proper filling out by health facility staff of the maternal cards on which details about the visits are recorded. But when mothers were asked for their maternal cards (Table 3.2), only a quarter could present them, another quarter reported that they had lost their cards, and more than thirty per cent reported the card was in another location. LQAS Report October-November 2003 page 19 of 117

26 As for whether they made the recommended number of visits, this question was put only to those mothers who presented their cards (to avoid the recall bias often encountered in questions of this nature), and the interviewers copied the number of visits noted on each woman s card directly into the questionnaire. Table 3.2 shows that of the few mothers who had cards, slightly more than one third (35.9 per cent) had made four or more antenatal visits, and another 20 per cent had made three visits. Three visits was the number recommended by the Ministry of Health before the advent of PMTCT. If this result is generalized to the population of all mothers with infants, it suggests that these women may be open to making a fourth visit if it was suggested to them. However, this result may be somewhat biased since women who have maternal cards may be more faithful users of ANC services. Table 3.2: Mothers Use of Antenatal Care Services, LQAS Survey, Uganda, Indicator % Confidence Reporting interval Attended ANC Mother asked for maternal card: Showed card Lost card Never had card Card in another location Other Never went to ANC Number of antenatal care visits recorded on card: Delivery in a Health Facility A second key element of the PMTCT intervention is that pregnant women deliver in a health facility, and the study measured this indicator by asking mothers where they had delivered their last child. The results presented in Table 3.3 show that half of mothers had their most recent delivery in a health facility, and the other half delivered at home. In order for HIV infected mothers and newborns to receive antiretroviral treatment (ART) they need to deliver at a health facility. Even mothers who deliver at home, however, can better avoid the risk of MTCT if there is a clinically trained provider present who can provide ART. Accordingly, the study asked mothers who attended ANC if they delivered under the care of a trained provider (a doctor, midwife, or nurse). As shown in Table 3.3, just over half of mothers did so, another 20 per cent delivered under the care of family members, 16 per cent were assisted by TBAs, and 8 per cent delivered on their own without any assistance. These findings indicate that of the half of women who deliver at home, 50 per cent may be exposing their infants and those assisting the birth to the risk of HIV. LQAS Report October-November 2003 page 20 of 117