HIV knowledge, attitudes, practices and population size estimates of fisherfolk in Uganda by IOM Uganda

in Six Districts in Uganda November 2013

HIV Knowledge, Attitudes and Practices and Population Size

Estimates of Fisherfolk in Six Districts in Uganda November 2013

COPYRIGHT The opinions expressed in the report are those of the author and do not necessarily reflect the views of the International Organization for Migration. Financial support was provided by the Partnership on Health and Mobility in East and Southern Africa (PHAMESA), a programme of the International Organization for Migration. Publisher: International Organization for Migration (IOM) IOM is committed to the principle that humane and orderly migration benefits migrants and society. As an intergovernmental organization, IOM acts with its partners in the international community to: assist in meeting the operational challenges of migration; advance understanding of migration issues; encourage social and economic development through migration; and uphold the human dignity and well-being of migrants.

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HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

FOREWORD The purpose of this study is to provide information that will enable policymakers and practitioners to design more effective HIV prevention programmes for Ugandan fishing communities. This is important not only because fishing communities represent one of the most marginalized and poverty stricken populations within the country, it is also important because these communities are pivotal in the ongoing national struggle against HIV as a whole. While this study does not present new data on the issue of prevalence, the study is driven by recent studies which indicate that the rates of HIV prevalence within fishing communities is three to four times that of the general population. There are approximately 130,000 people that live within fishing communities in Uganda. These communities support one of Ugandaâ&#x20AC;&#x2122;s most important and productive industries and at the same time providing income for some of Ugandaâ&#x20AC;&#x2122;s poorest citizens. Fisher folk are highly mobile given that much of the work is seasonal and necessitates moving within various landing sites. Work in the fishing industry is unpredictable, cash based, hard and frequently dangerous. Such conditions have given rise to various behavioural dynamics in fishing communities, particularly sexual behaviours which have been identified as key determinants of HIV infection. However, it is important that the fight to combat HIV within these communities not be reduced to a simple condemnation of sexual behaviours. The issue of the high HIV prevalence rates within such communities can only be understood in relation to a complex interplay of factors including vulnerabilities caused by the high degree of mobility, the failure to address the knowledge, attitudes and practices of these communities in HIV programming, and the inability of basic services to embrace the tempo and mobility demanded by the needs of the fishing industry. The particular purpose of this study was to look at the various factors related to knowledge, attitudes and practices which underlie the high HIV prevalence rates within fishing communities, and to look at these factors at an unprecedented scale. The study was designed on this scale, and in this form, to identify key factors required to drive effective, remedial action. As such, this study not only highlights the need for aggressive HIV prevention and response in the fishing communities, it also provides the basis of a tailored response. In particular, it highlights the need for increased, targeted health education with emphasis on the determinants of the disease and the need to improve access to HIV services through reducing distance, travel times and number of clinic visits. The study also focuses on the need to increase availability of resources needed for better HIV and AIDS care service delivery and to provide targeted communication interventions aimed at achieving behavioural change. IOM wishes to thank you for your interest in this study, and offer our hopes that it will help inform and strengthen HIV and AIDS programming for this highly vulnerable community.

Gerard Waite Chief of Mission IOM Uganda

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

ACKNOWLEDGMENTS This study was conceived and commissioned by the International Organisation for Migration and implemented by a study team from Makarere University, Kampala. Particular acknowledgement goes to the team leaders for this study from both institutions, Dr Bernadette Ssebadduka, Dr David Mafigiri and Dr Paul Bukuluki respectively. Special thanks go to all the respondents in the 42 fishing communities for their active participation and without whom this study could not have been possible. We would also like to thank all key informants who offered their time to be interviewed for this study. We are particularly grateful to the Local council and Beach Management Unit leaders that sacrificed their time to work with the study team to identify and select the respondents. Without their support, the fieldwork would have proved much more difficult. Data collection also depended on the hard work and commitment of numerous research assistants and supervisors: Ronald Luwangula, Ismail Nyanzi Ddumba, Florence Ayebare, Tony Onen Oci, Florence Namutiibwa, Irene Kisakey Sheila, Robert Bakonoma, Judith Birungi Nyanzi, Jane Nankinga, Amina Nalwoga, Mustapha Mubiru, Petra Babirye, Juma Oswald, Proscovia Nambuusi, Yofesi Baluki Kitholhu, Alfred Masereka, Elizabeth Tubasise, Robert Byaruhanga Kalende, Edward Atuhairwe, Rabson Masereka, Stella Wadiru. Isabella Kisa Wanadi, Adiga Stephen, Adiru Tamali, Jimmy Obonyo, Caroline Amony, Fiona Aber, Geoffrey Kilama. Finally, we would like to thank Mr. Micheal Odie for his dedication to data management and analysis.

Sincerely,

Gerard Waite Chief of Mission IOM Uganda

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Acronyms and Abbreviations ABC

Abstinence, Be Faithful and Condom use

AIDS

Acquired Immunodeficiency Syndrome

ANC

Antenatal Clinic

ART

Antiretroviral Treatment

ARV

Antiretroviral Drugs

BCC

Behaviour Change Communication

BMU

Beach Management Unit

CBOs

Community Based Organizations

DFO

District Fisheries Officer

DHO

District Health Officer

FGDs

Focus Group Discussions

HCT

HIV Counselling and Testing

HIV

Human Immunodeficiency Virus

IDI

In-depth Interview

IEC

Information, Education, Communication

Key Informants

MAAIF

Ministry of Agriculture, Animal Industry and Fisheries

MARP

Most-at-risk-populations

MOH

Ministry of Health

NGO

Non-Government Organization

STI

Sexually Transmitted Infections

EMTCT

Elimination of Mother to Child Transmission

STI

Sexually Transmitted Infections

UBOS

Uganda Bureau of Statistics

UNAIDS

nited Nations Joint Programme on AIDS

UNCST

Uganda National Council of Science and Technology

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

CONTENTS Foreword

Acknowledgments

Acronyms and Abbreviations

Executive Summary

1. Background 10 1.1.

HIV and AIDS in Uganda

1.2.

HIV and AIDS in Fishing Communities

Study Rationale and Objectives

Methodology

3.1.

Study Design

3.2.

Study Sites and Population

3.3.

Sample Size Determination and Sample Selection

3.4.

Data Collection

3.4.1.

Questionnaire-Based Survey

3.4.2.

Focus groups

3.4.3.

In-depth interviews (IDI)

3.4.4.

Population size estimation

3.5.

Quality Control Issues

3.6.

Data Management and Analysis

3.7.

Ethical Considerations

3.8.

Limitations of the Study

Results

Social-Demographic Characteristics

4. 4.1.

4.1.1.

Sex and Age of respondents

4.1.2.

Levels of education among respondents

4.1.3.

Marital status

4.1.4.

Religion

4.1.5.

Fishing and fishing-related Work

4.1.6.

Duration of the stay in the fishing community

4.2.

Mobility Characteristics

4.3.

HIV and AIDS Knowledge

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

4.3.1.

HIV and AIDS awareness

4.3.2.

Knowledge of methods of HIV prevention

4.3.3.

Beliefs and perceptions about HIV and AIDS

4.3.4.

Comprehensive HIV Knowledge

4.3.5.

Knowledge of Prevention of Mother-to-Child Transmission of HIV

4.3.6.

Knowledge about antiretroviral treatment

4.3.7.

Expanded knowledge about ARVs

4.3.8.

Knowledge about Source of ARVS

4.3.9.

Source of HIV and AIDS information

HIV and AIDS Related Attitudes

4.4.

4.4.1.

Stigma

4.4.2.

Attitudes toward negotiating safer sex

4.4.3.

Perceived norms about abstinence and faithfulness

4.4.4.

Perceptions about condom use education for children aged 12-14

HIV Related Sexual Behaviours and Practices

4.5.

4.5.1

Primary and Secondary Abstinence

4.5.2.

Age at sexual initiation

4.5.3.

Condom use at sexual debut

4.5.4.

Multiple Sexual Partnerships

4.5.5.

High Risk Sexual Intercourse

4.5.6.

Cross-generational sex

4.5.7.

Condom Use Practices

4.5.8.

Condom use with various partners

4.5.9.

Initiating the discussion on condom use in a relationship

4.5.10.

Transactional Sex

4.5.11.

Condom use during transactional sex

4.6.

Alcohol use during Sex

4.7.

HIV Risk Perception

4.8.

Self-Reported Prevalence of Sexually Transmitted Infections (STI)

4.9.

Access to HIV Counselling and Testing

4.10. Susceptibility and Vulnerability of Fishing Communities to HIV

4.11. HIV Response in Fishing Communities

4.11.1.

Availability of HIV Related Services

4.12. Location and Population Estimates of Fishing Communities

Conclusion and Recommendations

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

LIST OF TABLES Table 1: In-depth Interviews with selected key informants

Table 2: Respondentâ&#x20AC;&#x2122;s Religion by gender

Table 3: Background characteristics of respondents by gender (N=1971)

Table 4: Mobility of Fisher folks by gender

Table 5: Knowledge of HIV prevention methods by district

Table 6: Beliefs and perceptions about HIV

Table 7: Comprehensive Knowledge about HIV

Table 8: Knowledge of drug treatments for AIDS

Table 9: Knowledge of sources of ARV drugs

Table 10: Main channels of communication for HIV and AIDS information

Table 11: Most important messages learnt

Table 12: Accepting attitudes toward those living with HIV and AIDS

Table 13: Attitudes towards negotiating safer sex

Table 14: Primary and secondary Abstinence

Table 15: Age at sexual debut and condom use at fist sex

Table 16: Number of sexual partners in the last 12 months

Table 17: Lifetime sexual partners

Table 18: High risk sex in the past 12 months

Table 19: Factors associated with condom use at last sex among participants aged 15-59

Table 20: Condom use by partner type in the last 12 months

Table 21: Initiating discussion on condom use

Table 22: Transactional Sex by Background characteristics

Table 23: Reasons for perceived risk of HIV by gender

Table 24: Reasons why partner is at risk of HIV

Table 25:Self-reported prevalence of STIs and STIs symptoms

Table 26: STI Treatment seeking

Table 27: HIV testing history

Table 28: Organisations providing HIV and AIDS services in fishing communities

Table 29: Location and population estimates of fishing communities

List of Figure Figure 1: Distribution of survey population by age group and sex

Figure 2: Marital Status of Respondents

Figure 3: Knowledge of HIV prevention methods by gender

Figure 4: Knowledge of prevention of mother to child transmission

Figure 5: Expanded Knowledge of ARVs

Figure 6: Proportion of women and men who express accepting attitudes towards PLHIV by district

Figure 7: Proportion of women and men who express accepting attitudes towards PLHIV by age

Figure 8: Perceived norms

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

EXECUTIVE SUMMARY This report presents study findings and recommendations of the IOM study entitled ‘HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisher Folk in Six Districts in Uganda.’ The study and covers 42 fishing communities which contain a population of more than 61,545. The study focused on perceived vulnerability and risk reduction strategies in fishing communities in Arua, Apac, Kasese, Masaka, Rakai and Wakiso districts. The geographical locations and population size estimates of the surveyed fishing communities are also specified. Field work for this ‘mixed-method’ study was conducted in early 2013. Data was collected through individual structured interviews, focus group discussions, key informant interviews (KIIs), and document review. A total of 1971 respondents aged 15-59 were interviewed for the quantitative aspects of the research. In addition, 193 respondents participated in focus group discussions and 27 key informants received in depth interviews, in order to obtain qualitative information. Summary findings

Demographic characteristics Of the 1971 respondents, majority (53%) were men. The mean age of the participants was 30 years, with more than half (56%) aged less than 30 years. 53 per cent were married, 82 per cent were Christian, and 56.3 per cent had attained primary education. The majority of men (43%) were working as fishermen, and 24 per cent as fish mongers. About 27.3 per cent of the women were fishmongers, 20 per cent were traders, managing shops or touting local merchandise. The majority of the respondents (55% of men and 44% of women) had been residing in their community for less than 5 years, whereas 55.6 per cent reported having ever travelled away from their community for more than a month in the 12 months preceding the study.

HIV and AIDS-related knowledge The majority (89% of men and 88% of women) was familiar with the most common means of HIV prevention; that is, using condoms, limiting sex to one partner who is not infected and abstaining from sex. Majority were also aware that a healthy looking person could have the HIV virus, that HIV cannot be transmitted through supernatural means or through sharing food with a person living with HIV. Nonetheless, some isolated pockets of misconception still abound. For example, 38 per cent of women and 35 per cent of men agreed that one can get HIV through mosquito bites. In terms of knowledge related to PMTCT and antiretroviral drugs, females had a greater knowledge relating to mother-to-child HIV transmission than males. For example, 90 per cent of women compared to 83 per cent of men were more likely to know that HIV can be transmitted from a mother to her child through breastfeeding. The level of comprehensive HIV knowledge among the respondents is moderate; standing at 45.8 per cent among women and 48.8 per cent among men. The level of comprehensive knowledge is higher among those with secondary or higher level of education compared to those with lower levels of education.

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Source of HIV information The radio and health workers were identified as the commonest source of HIV and AIDS information. The most commonly reported important messages learnt from these sources concerned condom use (31.9%), be faithful to one sexual partner (18.8%), abstaining from sex (15.8%), and the need to get tested for HIV (13.6%). These messages seem to reflect the primacy given to HIV prevention among fisher folk.

HIV and AIDS attitudes The majority of people in fishing communities have accepting attitudes towards those with HIV; over 96 per cent would care for a relative with HIV in their own homes, and over 85 per cent think an HIV-positive teacher should be allowed to continue teaching. About 59 per cent of women and 53 per cent of men say that if a member of their family were infected with the AIDS virus, they would not necessarily want it to remain a secret. In addition, a high proportion of respondents (92%) believed that a woman is justified to negotiate safer sexual relations with her husband, either by refusing to have sex or asking him to use a condom if she knows he has a sexually transmitted infection.

HIV risk behaviour Only 7 per cent of respondents had never had sex (primary abstinence). The mean age at first sexual intercourse was 15.4 years for women (Median 16; SD Âą5.1 years) and 16.2 years for men (Median 17; SD Âą5.4 years). Nearly a third of women (33.5%) and more than a quarter of men (28.1%) aged 15â&#x20AC;&#x201C;59 had heterosexual intercourse before they were 16 years. Only 17.5 per cent of the respondents reported condom use at first sexual intercourse. Among sexually experienced respondents, only 12 per cent reported no sexual partners in the 12 months preceding the survey (secondary abstinence). Among respondents who had had sexual intercourse in the preceding 12 months, 45.8 per cent reported having had two or more sexual partners. About 7 per cent of women and 19 per cent of men had had sex with five or more partners. Thus, multiple sexual partnerships are common, and more specially among men than in women. 45.5 per cent of women and 65 per cent of men reported either engaging in high-risk sex or having had sex with a non-marital and non-cohabiting partner engaged in high-risk sex. Among these, 43.8 per cent of women and 47.1 per cent of men had had sex with between two and four casual partners in the preceding 12 months. Respectively, 71.9 per cent and 55 per cent of women and men, had had at least one regular partner in the same period. Transactional sexual relationships were prevalent in fishing communities; over 34 per cent of men and 24 per cent of women had engaged in transactional sex in the 12 months preceding the survey. Only 41 per cent of women and 44 per cent of men reported consistent condom use during transactional sex. Among all sexually active respondents, condom use at last sexual intercourse was 26 per cent. Respondents who reported multiple sexual partners were more likely to have used a condom at the last occasion they had sex compared to those without multiple partners (37% vs. 18%). Analysis of condom use by partner type indicates consistent condom use being higher with casual and regular partners, but very low with spouses. Men were generally more likely to report consistent condom use with

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

casual and regular partners than women. Dislike for condoms, alcohol abuse, and difficulty in negotiating for use of condoms, especially in the context of transactional sex, were cited as some of the factors contributing to inconsistent condom use.

HIV risk perception About 97 per cent of the respondents were aware that people in fishing communities (as specific population groups) are at an elevated risk of HIV infection, with 63 per cent of men and 68 per cent of men reporting that they were personally at risk of HIV infection mainly because of engaging in unprotected sex. When asked whether their partners were equally at risk, 65 per cent of men and 74 per cent of women believed that their partners were at an elevated risk of HIV infection mainly because their partners were not trustworthy and/or have sex with multiple partners.

Sexually transmitted infections (STIs) and treatment seeking behaviour The proportion of participants who reported having an STI or having experienced symptoms perceived to be an STI in the last 12 months was 41 per cent among women and 30 per cent among men. Regarding treatment seeking behaviour, it was found that over 86 per cent of women and 89 per cent of men had sought treatment for STIs in the past 12 months, mainly from private and government clinics; suggesting good treatment seeking behaviours among women and men in fishing communities.

HIV counselling and testing Overall, 86 per cent of the respondents had ever tested for HIV, with over 76 per cent having done so in the past 12 months. The majority (63% of women and 56% of men) tested at government facilities. This depicts a relatively positive attitude towards HIV counselling and testing.

Drivers of HIV in fishing communities A range of factors were reported to increase the susceptibility of HIV in fishing communities. These include the mobility of fisher folk, access to daily disposable income, risky nature of the fishing occupation leading to fatalistic attitudes, widespread alcohol consumption, multiple sexual partnerships, a culture of sharing women, and poverty.

Population estimates The 42 fishing communities had a total population of 61,545 people, 30,689 (49.9 %) of whom were men. This is detailed in Table 30.

Access to HIV prevention, care and treatment services Even where HIV and AIDs services were known to be available, they were largely inaccessible in terms of distance and cost of travel to access them. Most fishing communities are remote and health facilities are distant; with distances of some communities to their nearest health facility ranging from 7km to 35 km. Most of the NGOs providing specific HIV service in some fishing communities rely on community outreach. These outreach programmes were perceived by community members to be intermittent, especially for fishing communities located either on islands or surrounded by the National park.

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Conclusion and recommendations What works and what remains to be done? Overall, there is a high level of knowledge and awareness about HIV and AIDS transmission and prevention in fishing communities. However, misconceptions about HIV and AIDS still prevail to unacceptably high levels. While such high levels of awareness may be suggestive of effective interventions thus far, the persistent misconceptions indicate potential limitation of conventional approaches being implemented nationwide. Thus, there remains a need to tailor conventional interventions to the socio-cultural context in fishing communities. In addition, the high levels of knowledge of HIV transmission and prevention have not necessarily translated into adoption of safer sex practices and behaviour throughout the fishing communities. Our data suggest that a holistic approach is required, which combines quality health services with locally appropriate, targeted behavioural change educational and community development efforts tailored to the fishing community. KEY MESSAGES: 1. Fishing communities remain at significantly high risk of exposure to HIV yet are underserved by current HIV prevention programmes, hence the urgent need to intensify tailored HIV interventions for fisherfolk. 2. Despite high levels of awareness about HIV and AIDS and a wide general knowledge about major concepts of HIV transmission, prevention, and treatment, profound misconceptions still abound among ‘fisher folk’, justifying intensified HIV education on these communities. 3. Knowledge of HIV transmission and prevention has not translated into widespread adoption of safer sex practices and behaviour, therefore, the HIV programmes need to place emphasis on social and behaviour change communication. 4. Interventions should be locally appropriate to the identified needs of various fishing communities, and should be tailored to the entire fishing community including all its sub-groups

1. BACKGROUND 1.1.

HIV and AIDS in Uganda HIV and AIDS continue to pose a significant public health and development challenge in Uganda. The 2011 Uganda AIDS Indicator Survey estimated HIV prevalence at 7.3 per cent among adults (ages 15– 49) and 0.6 per cent among children under 5. HIV prevalence is higher among women than men: 8.3 per cent in comparison to 6.1 per cent. It is higher among women in urban areas (10.7%) than in rural areas (7.7%), but the same, 6.1 per cent, for men in both areas (Ministry of Health, 2012). The incidence of new infections is also high. In 2009 alone, the number of estimated new HIV infections in the country was 124,000, with 20 per cent in children and 55 per cent in women. This is twice as many as the number of annual AIDS deaths (64,000) and three times the net enrolment for ART in 2009 (Uganda AIDS Commission, 2011). According to a 2009 HIV modes of transmission study, heterosexual transmission accounted for 75 per cent of new HIV infections in the country, while 18 per cent to 20 per cent were due to mother-tochild transmission (Government of Uganda, 2010; Wabwire-Mangen, Odiit, Kirungi, & Kisitu, 2009).

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Although Uganda’s HIV epidemic affects all population groups, there are populations that are more at risk of HIV infection. These key populations include female sex workers and their clients and partners, fisher folk, and other mobile populations (Uganda AIDS Commission, 2011).

1.2.

HIV and AIDS in fishing communities Fishing communities in developing countries have been identified in the past decade as a sub-population at significant risk of contracting HIV (Kissling et al., 2005). Available evidence indicates that in Uganda people in fishing communities are at greater risk to HIV than the general adult population (Asiki et al., 2011; Gordon, 2005; Grellier, Tanzam, Lambert, & Howard, 2004; Karukuza & Bob, 2005; Opio, Muyonga, & Mulumba, 2011; Seeley & Allison, 2005; Seeley, Nakiyingi-Miiro, et al., 2012; Tanzarn & Bishop-Sambrook, 2003; Wabwire-Mangen et al., 2009). In Uganda, estimates of HIV prevalence reveal that infection rates in the fishing communities are almost 3-4 times higher than the national average prevalence for adults aged 15-49 years. For example, a 2011 HIV Sero-Behavioural Survey in fishing communities of the Lake Victoria basin of Uganda reported an HIV prevalence of 22 per cent, with higher prevalence among women (25.1%) compared to men (20.5%)(Opio et al., 2011). Other studies in fishing communities in Uganda have also found high HIV rates, standing at between 23-35 per cent (Asiki et al., 2011; Seeley, Nakiyingi-Miiro, et al., 2012; Sigirenda et al., 2012). Other studies have identified a combination of factors that increase HIV susceptibility and/or contribute to a high-risk environment for HIV exposure in fishing communities. (Asiki et al., 2011; Kissling et al., 2005; MacPherson et al., 2012; Mojola, 2011; Opio et al., 2011; Seeley & Allison, 2005; Seeley, Nakiyingi-Miiro, et al., 2012; Seeley, Watts, et al., 2012; Sigirenda et al., 2012; Tumwesigye et al., 2012). These include the nature of the occupation, which is characterized by high mobility and long absences from home ; the risky nature of the fishing occupation, which fosters risk taking and fatalistic attitudes; access to daily disposable income in a general context of poverty contributing to transactional and cross-generational sex; their demographic profile (they are often young and sexually active); fragmented and diverse social and cultural mixing in fishing communities compared to behaviour in stable communities; a sense of anonymity which allows for more sexual freedom; high rates of alcohol and drug abuse that engenders risky sexual behaviour; the availability of sex workers in fishing community; and gender inequality. The proportion of people infected with HIV in a fishing community, and the impact of AIDS-related morbidity and mortality in that community, largely depends on the extent to which the above factors occur and on how they combine to increase vulnerability(Gordon, 2005; Grellier et al., 2004; Tanzarn & Bishop-Sambrook, 2003). Further, many of the above factors make ‘fisher folks’ not only vulnerable to HIV but also more likely to miss out on access to prevention, treatment and care(Allison & Seeley, 2004; Asiki et al., 2011; Grellier et al., 2004) Since the onset of the HIV epidemic, the essential component of efforts to better understand HIV dynamics has been measuring people’s knowledge, attitudes, and the level and frequency of risk behaviours related to HIV transmission (MacLachlan et al., 2002; Ugarte, Hogberg, Valladares, & Essen, 2013). These aspects provided important information to identify populations most at-risk of HIV, as

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

well as to determine the needs, barriers and goals of HIV prevention (Ugarte et al., 2013). For instance, assessing misconceptions about HIV transmission is important for determining the changing perception that result from preventive efforts. Misinformation about HIV has been strongly associated with HIVrelated stigma and discrimination and with high rates of HIV risk taking behaviours (MacLachlan et al., 2002). Perceived vulnerability is also critical to an individual’s precautionary behaviour (Gerrard, Gibbons, & Bushman, 1996; Smoak, Scott-Sheldon, Johnson, & Carey, 2006). However, few studies have sought to determine the knowledge, attitude, behaviour and practices regarding HIV/AIDS among women and men in fishing communities in Uganda. Some of the existing studies are limited to fishing communities on specific lakes, and therefore not representative (Karukuza & Bob, 2005; Opio et al., 2011). This study was therefore designed to address this information gap. The study was designed to generate comprehensive information on HIV related knowledge, attitudes, practices and population size estimates in fishing communities. In addition, the study will generate information on the range, availability and utilization of HIV services; because they have a bearing on both HIV prevalence and behaviours. This information is expected to guide the development and implementation of combination HIV prevention programmes for fisher folk in Uganda.

STUDY RATIONALE AND OBJECTIVES The objectives of the study were to: 1. Provide an understanding of HIV and AIDS knowledge, attitudes, practices and perceived HIV vulnerabilities in selected fishing communities in six districts of Uganda. 2. Provide information on sexual and behavioural dynamics, as well as risk reduction strategies for HIV, AIDS, STIs and unwanted pregnancies. 3. Specify the geographical locations of fishing communities in the study districts and their estimated population. 4. Make recommendations for improved HIV programming within a combination HIV prevention framework.

3. METHODOLOGY 3.1. Study Design The study followed a multi-method design and included qualitative and quantitative components, namely: 1. A questionnaire-based survey of women and men, aged 15 – 59 years in fishing communities. 2. A focus group component for men and women, aged 15 – 59 years, representing different categories of people in fishing communities such as boat owners, barias , net repairers etc.

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

3. An in-depth interview component focusing on selected key informants such as leaders of Beach Management Units (BMU), District Fisheries Officers, staff from organizations providing HIV services and community leaders (for example, local council and religious leaders). 4. Population size estimation

3.2. Study Sites and population The study was conducted in 42 fishing communities of the six districts, namely, Apac, Arua Kasese, Masaka, Rakai and Wakiso (See Table 29). The study targeted men and women in the selected fishing communities in the six study districts. The primary recruitment criteria included ages 15 to 59 and equal distribution between districts.

3.3. Sample size determination and sample selection To determine the sample size, we considered: (1) an estimated HIV prevalence 28.8 per cent in fishing communities with a 95% confidence interval (CI); and (2) a non-response rate of 20 per cent (Asiki et al., 2011; Seeley, Nakiyingi-Miiro, et al., 2012) . In total 1,971 respondents were involved.

3.4. Data Collection 3.4.1. Questionnaire-Based Survey We used a structured questionnaire to collect information on the socio-demographic characteristics of sampled respondents, HIV related knowledge, mobility, awareness and knowledge of HIV and AIDS, attitudes and perceptions about HIV, HIV-related behaviour and perceived vulnerability to HIV. 3.4.2. Focus Groups A total of 18 FGDs were conducted with men and women, aged 15 to 59 years, representing different categories of people in fishing communities such as boat owners, barias, net repairers and local area traders. FGDs were equally distributed between the six study sites, and were stratified based on sex and age, that is, women aged 15-24 years, women aged 35-59 and men aged 15-19. The FGDs, which lasted between one and a half hours and two hours, were conducted in participantsâ&#x20AC;&#x2122; language of preference. An average of 11 respondents participated in each FGD and in all, there were 193 respondents (129 female and 64 male). The sessions were moderated by a facilitator and a note taker who had been trained to conduct FGDs and to document the verbal responses and nonverbal cues during the discussions. With the consent of FGD participants, the discussions were digitally recorded. Respondents who participated in the FGD were excluded from participating in the survey due to their prior exposure to information being sought.

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

3.4.3. In-depth interviews (IDI) A total of 27 IDIs, each lasting approximately one hour, were conducted with purposely selected key informants, such as leaders of the Beach Management Unit (BMU), community/local leaders, and staff from the District Health Office (DHO), District Fisheries Officers and their Assistants, and staff of organizations providing HIV services to fishing communities. They were conducted at venues convenient to participants where discussion could be conducted in confidence. All FGDs and IDIs were conducted in the language of preference of the participant, and discussions were digitally recorded. It should be noted in Apac, Wakiso, Kasese no KII were available at the time of the study, hence no data was collected. On the other hand, Masaka and Rakai have the same service providers therefore one KII was interviewed as indicated in Table 1. Table 1: In-depth Interviews with selected key informants IDI Categories Leaders of Beach Management unit (BMU)

Total

Apac

Arua

Wakiso

Kasese

Masaka

Rakai

Official from the District Health office

District Fisheries Officer (DFO)

Staff of organizations providing HIV and /AIDS services

Community leaders (e.g. LC official, religious leader etc)

Total

3.4.4. Population size estimation We determined the population estimates of fishing communities through a combination of methods and sources namely: BMU and local council registers, district planning unit registers and interviews with community leaders. In Uganda, BMUs routinely collect and update their registers for purposes of monitoring the local fishing industry. Similarly, in Uganda, the lowest administrative unit is a village. The Village unit is governed by a Local Council, which routinely collects selected demographics including population size of the village. Thus, together, these records were considered highly accurate to estimate local population sizes.

3.5.

Quality Control Issues Pre-testing of study instruments The survey instrument was developed on the basis of standardized questionnaires (Ministry of Health, 2012; MoH & ORC Macro, 2006) that have been tested and used to conduct HIV and AIDS knowledge, attitudes, beliefs and behaviour surveys. The instrument measured HIV-related knowledge, HIV related attitudes and awareness, and HIV-related behaviours and practices. The questionnaire was pilot tested among 30 people (not included in the final survey) as part of fine tuning and implementation validity.

Training of field teams Field teams were trained about the protocol and procedures. This included focusing on the study objectives and practicing with the data collection tools.

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Training of data collectors also covered a range of ethical issues and study teams identified support systems in the community for referral of any participants requiring support or assistance during the study. Team leaders and supervisors maintained control over all digital files and written notes and all data were kept securely.

Pre-study visits Prior to conducting interviews, three separate teams of research officers travelled to each of the six districts. The pre-study visit included identifying key contacts in the different fishing communities, who would then link the research team to the study population. Information obtained included; primary contactsâ&#x20AC;&#x2122; name and telephone number, level of influence in identifying the target population, as well as what was needed to get good participation from people in fishing communities. At the time of interviews, the research team identified themselves to the contacts, who acted as community guides during the field data collection exercise.

Supervision On-site supervision of data collection was done by a team of experienced researchers (supervisors) in the six districts. Working under the guidance of IOM and the consultants, the supervisors were responsible for: coordinating and overseeing the data collection process, including making contacts with the BMUs at landing sites where data would be collected, and keeping a log of activities; direct-onsite supervision of data collection exercise; ensuring that ethical and quality standards were maintained; reviewing completed KAP survey questionnaires on a daily basis to ensure completeness and accuracy; and ensuring safe and confidential data storage in the field and during transfer.

3.6. Data Management and Analysis Quantitative data was captured using MS Access and analysed in STATA (Version 11). Descriptive statistics were used to illustrate demographic characteristics. Univariate statistics were used to compare distributions by gender, age, site, and education. Chi-square tests were used to assess significance of observed variations across key variables.

Qualitative data All FGD and IDI were recorded, transcribed, translated and entered into MS Word. Transcription of FGD was aided by notes taken during discussions. Transcripts were checked for accuracy and then imported into qualitative analysis software (Nvivo 8) for coding and thematic analysis. Data was analysed following the principles of thematic analysis, according to the precepts of grounded theory (Bernard, 2006).

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

3.7. Ethical Considerations Ethical approval for the study was obtained from the Makerere University School of Public Health (MUSPH) Higher Degrees, Research and Ethics Committee (HDREC). In addition, national clearance was obtained from the Uganda National Council for Science and Technology (UNCST). Further, permission to work in the district and fishing communities was provided by community leaders (Local council leader, BMU leaders) in the selected fishing communities as well as district level representatives from the respective districtsâ&#x20AC;&#x2122; fisheries office, and/or health office (DFO/DHO). Written informed consent was obtained from all individuals participating in the interviews and focus groups using their preferred local language. Before enrolment into the study, the respondents were informed about the aims of the study, their discretion to participate or withdraw at any time and were assured that all information obtained from them would be kept confidential. The anticipated benefits or risks of the study to the participants or the community were clearly explained and all the participants were given an opportunity to express whether they had understood the objectives of the study and what was expected of them as respondents.

3.8. Limitations of the Study This was a cross sectional study. The survey method depended on self-reported data, which can potentially be limited by inaccurate reporting due to poor memory or misunderstanding of questions. Moreover, given the sensitive nature of the survey, social desirability bias can potentially occur. Also, there is the possibility of recall bias since respondents were expected to provide information on previous behaviours. However the large sample size and the quality control measures discussed above served to strengthen the validity of study findings. Additionally, validity was increased by methodological triangulation; therefore the findings may be generalizable to similar fishing communities in Uganda.

4. RESULTS 4.1. Social-Demographic characteristics 4.1.1. Sex and Age of respondents The sample comprised of 1,971 respondents, of whom the majority (53%) were men. The mean age of the respondents was 30.3 years for men (Median 28; SD Âą 10.4 years) and 28.5 years for women (Median 27; SD Âą 9.4 years). More than half of the respondents (56.5%) were aged less or equal to 30 years. More than a third of the respondents (36.6%) were aged 15-24 years. The age group 50-59 years constituted only 4.8 per cent of the respondents (Figure 1).

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Figure 1: Distribution of survey population by age group and sex

4.1.2. Levels of education among respondents Respondents were asked to indicate the highest level of education attained. The majority of respondents, (55.9% of men and 56.8% of women) had only attained primary school level education. 34.3 per cent of men and 25.5 per cent of the women had had secondary or higher education. About one per cent of the respondents had no formal education; with nearly twice as many women (16.6%) compared to men (9.1%) reporting they had never attended school. 4.1.3. Marital status More than half (58%) of the respondents were married, with more men (60%) compared to women (56%) being married. About 32 per cent of men and 25 per cent of women were single. About 10 per cent of both men and women were divorced or separated. More women (13%) reported being divorced/separated compared to men (7%). Women (6.9%) were also more likely to report being widowed than men (1.8%). Figure 2: Marital Status of Respondents

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

4.1.4. Religion The majority (82%) of the respondents were Christians of various denominations with Catholic being predominant (47%), followed by Anglican (26.5%). 17.7 per cent of the respondents were Muslim. Table 2: Respondentâ&#x20AC;&#x2122;s Religion by Gender

Religion Men

Female

# men

# women

Catholics

49.6

515

44.1

411

Anglican

24.7

257

28.5

266

Other Christians

7.7

9.4

Muslims

17.6

183

17.8

166

Traditional

0.2

0.1

None/No religion

0.2

4.1.5. Fishing and Fishing-related Work The majority of men (43%) were mainly working as barias and fishmongers (24%), while women were mainly working as fishmongers (27%) and transient traders (20%) either managing shops or touting local merchandise as shown in Table 3. Table 3: Background characteristics of respondents by gender (N=1971)

Background characteristic

Male (n=1,039)

Female (n=932)

Apac

18.58 %

14.27%

Arua

16.36

17.06

Kasese

16.84

16.42

Masaka

16.36

16.95

Rakai

15.98

17.60

Wakiso

15.88

17.70

15-24

34.5

39.2

25-39

46.6

46.0

40-59

19.9

14.8

No education

9.05

16.63

Primary

55.92

56.76

Secondary +

34.26

25.54

District

Age

Education

Occupation Boat owner

4.80

0.86

Fish monger

23.82

27.33

Barrias

42.75

1.61

Other fishing related activities

7.69

4.29

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Trader (kiosk/shop owner or worker)

5.19

19.61

Bar/restaurant owner or worker

12.97

0.58

Farmer

4.42

6.22

Other small scale business

1.16

Students

3.46

5.79

Housewife

0.00

5.47

Other

6.15

9.86

â&#x2030;¤1 year

7.89

12.02

1-5 years

29.64

36.37

54.4

43.9

Visitor

0.38

0.64

Always/born in the community

7.60

6.87

Length of stay in current location

4.1.6. Duration of the stay in the fishing community Majority of respondents (54.4% of men and 44.9% of women) had been residing in the community for more than five years. About one in every ten people (9.8%) had been staying in the fishing community in which they were interviewed for less than a year (Table3).

4.2. Mobility Characteristics Mobility was cited as an important risk factor for HIV transmission (Seeley & Allison, 2005; Seeley, Watts, et al., 2012). The survey measured two related variables, namely: the number of times a respondent travelled away from home during the preceding 12 months and; duration (length) of stay away from home during those 12 months. Overall, 61.4 per cent of respondents reported having ever travelled and slept away from their community in the 12 months preceding the study. More men reported having travelled and slept away compared to women (66% compared to 56.2 %). With respect to the duration of stay away from home, more than half of both men (57%) and women (53%) had stayed away from home for more than a month in the 12-month period preceding this study. Table 4: Mobility of Fisher Folks by Gender

Gender Mobility during last 12 months

Overall ( n=1,971)

Male (n=1,039)

Female (n=932)

Ever slept away

61.4

66.03

56.22

Never slept away

37.85

33.21

43.03

Been away for a month

55.12

56.71

53.05

Been away for less than a month

43.97

42.27

46.18

Duration of Staying Away from Home During Last 12 Months

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Qualitative findings indicate that mobility was one of the major drivers of HIV transmission in fishing communities. Participants reported that there was a lot of movement in and out of fish landing sites and this was especially common with barias and sex workers. Some participants indicated that mobility contributed to fishermenâ&#x20AC;&#x2122;s vulnerability especially as some of them came to the landing site to fish, leaving their families behind. Similarly, sex workers were reported to move around various landing sites targeting fishermenâ&#x20AC;&#x2122;s income as well as a more competitive pay for the sex work.

4.3.

HIV and AIDS Knowledge Knowledge of how HIV is transmitted is one of several factors that enable people to protect themselves from HIV. Knowledge influences positive behaviour change and risk reduction behaviours such as abstinence, avoiding high risk sex, and correct and consistent condom use. In this survey, HIV and AIDS related knowledge in fishing communities was assessed through the following variables: 1. Whether participants had ever heard of AIDS; 2. Knowledge about specific means of transmission of the virus, 3. Beliefs and perceptions relating to HIV and AIDS; 4. Knowledge about mother-to-child transmissions; and 5. Knowledge about antiretroviral therapy.

4.3.1. HIV and AIDS awareness 99.9 per cent of the respondents had heard of AIDS; suggesting a high level of awareness of HIV and AIDS among all sub-groups of men and women in fishing communities. 4.3.2. Knowledge of methods of HIV prevention Unprotected heterosexual intercourse remains the main mode of HIV transmission among adults in Uganda. Consequently, HIV prevention efforts have mainly sought to reduce further sexual transmission through three programmatically important ways: promotion of sexual abstinence, mutually faithful monogamy among uninfected individuals, and condom use among the sexually active. During the study, men and women were prompted with specific questions about whether it is possible to reduce the chance of getting the virus that causes AIDS by using condoms, by having sex with just one partner who is not infected and has no other partners, and by abstinence. Results are shown in Figure 3 The majority of participants were familiar with the most common means of HIV prevention: 90.3 per cent of women and 91 per cent of men agreed that condom use could reduce the risk of getting HIV. About 96 per cent of women and 97.2 per cent of men knew that the risk of getting HIV could be reduced by having one sexual partner who is not infected with HIV. Overall, 88.4 per cent of men and 87.8 per cent women recognize that both using condoms and having one uninfected partner are methods to reduce the risk of getting HIV.

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Generally, the level of knowledge did not differ significantly by age, education, and marital status. However, there are notable differences in knowledge of HIV prevention by district (Table 5). For example, 97.1 per cent of the men in Masaka recognize that both using condoms and limiting sexual intercourse to one uninfected partner are ways to reduce the risk of getting HIV, compared with about 81.3 per cent of the men in Apac district. Data from FGD also revealed that most participants had sufficient knowledge about HIV and AIDS. Most people clearly knew how HIV was transmitted and were able to state a number of ways of preventing the spread of HIV. Participants reported that HIV transmission is mainly through sexual intercourse and sharing of sharp instruments. With respect to HIV prevention, condoms were the most commonly identified means of preventing HIV transmission. A few participants reported abstinence and avoidance of multiple sexual relationships as means of preventing HIV as well. Figure 3: Knowledge of HIV prevention methods by gender

Table 5: Knowledge of HIV prevention methods by district

Male

Female

Percentage who say HIV can be prevented by:

Using condoms

Limiting sexual intercourse to one uninfected partner

Using condoms & limiting sexual intercourse to one uninfected partner

Limiting sexual intercourse to one uninfected partner

Using condoms & limiting sexual intercourse to one uninfected partner

Abstaining from sexual intercourse

No of men

Abstaining from sexual intercourse

Apac

85.4

94.8

81.3

80.7

192

Arua

89.4

97.1

88.2

80.6

170

86.5

97.7

85.7

90.9

133

83.0

90.6

77.4

85.5

159

Kasese

87.4

98.9

86.3

96.6

Masaka

97.7

99.4

97.1

98.8

175

88.2

98.0

86.3

92.2

153

170

97.5

100.0

97.5

158

Rakai

92.8

100.0

92.8

Wakiso

92.1

92.7

86.1

91.0

166

95.1

98.2

93.9

95.7

164

89.1

165

90.3

93.3

85.5

90.9

165

Using condoms

No. of women

District

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

4.3.3. Beliefs and Perceptions about HIV and AIDS A prerequisite to reducing the risk of HIV transmission is identifying incorrect beliefs about HIV and AIDS to be targeted for intervention. Common misconceptions include the idea that all HIV-infected people always appear ill and the belief that the virus can be transmitted through mosquito or other insect bites, by sharing food with someone who is infected, or by witchcraft or other supernatural means. Table 6 shows the proportion of women and men who know that a healthy looking person can have HIV and who reject common misconceptions about HIV transmission. For example, 90.7 per cent of men and 90.8 per cent of women know that a healthy-looking person can have HIV. About 86.2 per cent of men and 85.2 per cent of women also know that the AIDS virus cannot be transmitted by supernatural means. In addition, 82.9 per cent of women and 85.8 per cent of women said a person cannot become infected with HIV by sharing food with a person who has AIDS. Fewer respondents however understand that HIV cannot be transmitted by mosquito bites (62.3 per cent of women and 65.6 per cent of men). In other words, about 38 per cent of women and 35 per cent of men were not aware that one cannot get HIV through mosquito bites. This shows that while most respondents demonstrated considerable knowledge of HIV and AIDS, significant pockets of misconceptions still abound. There are notable differences in beliefs and perceptions about HIV by education. For example, the proportion of both men and women who correctly rejected all the 4 local misconceptions about HIV and AIDS was consistently higher among those who have secondary or higher education compared to those with primary level education or those with no education at all (Table 6). During focus groups, participants were asked to mention some of the common HIV and AIDS related misconceptions and myths in the fishing communities. The myths mentioned include the perception that the â&#x20AC;&#x153;fish harvestâ&#x20AC;? is better after sex with particular females. Some participants also believed that HIV and AIDS is a curse and/or to be a result of witchcraft, as reflected in the voice below: Some of these people believe that particular women have good harvest luck once you have sexual intercourse with her. HIV/AIDS is a curse, that is, when one person gets it in a family, it is obvious that at least more than one family member will have to get it (FGD, Women, Arua). The people believe that HIV is caused by witchcraft (FGD, Women, Arua).

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Table 6: Beliefs and perceptions about HIV Male

Female

Percentage who say that:

Percentage who say HIV can be prevented by:

A healthy looking person can have the AIDS virus

The AIDS virus cannot be transmitted by mosquito bites

The AIDS virus cannot be transmitted by supernatural means

15-24

89.1

64.7

86.8

25-39

91.4

66.0

86.5

40-59

91.3

60.9

82.1

Total, 15-59

90.6

64.6

85.7

Married

91.1

65.3

Single

90.7

64.6

Divorced/ Separated

88.7

Widow/ widower

A person cannot become infected by sharing food with a person who has the AIDS virus

No. of women

No of men

A healthy looking person can have the AIDS virus

The AIDS virus cannot be transmitted by mosquito bites

The AIDS virus cannot be transmitted by supernatural means

86.8

357

89.9

63.6

85.8

82.7

365

84.0

474

91.6

62.2

84.6

80.7

429

86.5

207

89.1

59.4

81.2

87.0

138

85.5

1038

90.6

62.3

84.6

82.4

932

86.3

85.9

626

91.3

62.7

86.3

80.5

518

83.7

84.8

322

89.7

66.8

84.1

85.8

232

57.8

91.6

83.1

93.2

60.7

76.9

83.8

117

79.0

63.2

79.0

89.5

82.8

46.9

85.9

84.4

No education

89.4

61.7

85.1

81.9

87.1

50.2

85.2

81.9

155

Primary

89.4

59.0

85.2

83.1

580

90.0

60.3

84.3

80.9

529

Secondary +

92.7

74.4

86.8

90.5

356

94.5

77.0

84.9

86.1

238

Apac

89.1

67.7

85.9

87.5

192

90.2

62.4

77.4

85.0

133

Arua

85.9

73.5

78.2

81.8

170

87.4

63.5

79.9

78.6

159

Kasese

94.9

62.3

84.6

94.9

175

96.1

62.1

84.3

87.6

153

Masaka

91.2

59.4

91.8

82.4

170

88.0

70.9

94.9

82.3

158

Rakai

90.4

66.3

95.8

84.3

166

88.4

57.9

92.7

86.6

164

Wakiso

92.1

57.6

78.2

81.2

165

93.3

62.4

77.0

75.2

165

Age

Marital status

Education

District

4.3.4. Comprehensive HIV Knowledge Comprehensive HIV knowledge is an indicator derived from the percentage of respondents who can correctly identify five statements about HIV, namely: 1. people can reduce the chances of getting the AIDS virus by using a condom every time they have sex, 2. people can reduce the chances of getting the AIDS virus by having sex with just one partner who is not infected and who has no other partners, 3. people cannot get the AIDS virus from mosquito bites, 4. people cannot get the AIDS virus from sharing food with a person who has AIDS, and 5. A healthy-looking person can have the AIDS virus.

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Less than half (47.6%) of the respondents, aged 15-59 had comprehensive knowledge about HIV and AIDS (Table 7). A slightly higher proportion of men demonstrated comprehensive knowledge about HIV and AIDS than women (48.8% vs. 45.8%). Comprehensive HIV and AIDS knowledge is higher among those with secondary or higher level of education (58.1%) compared to those with primary level (43.2 %) or no education (40.6%) However, there was no significant difference in comprehensive knowledge across districts (p=0.065), marital status (p=0.086), and across age groups (0.824). Table 7: Comprehensive Knowledge about HIV

Age

Men

Female

Total

# men

# women

# overall

15-24

46.5

357

47.4

365

47.0

722

25-39

51.3

474

44.8

429

48.2

903

40-59

46.9

207

44.3

138

46.0

345

Total, 15-59

48.75

1038

45.8

932

47.6

1970

No education

46.81

36.77

155

40.56

249

Primary

43.62

580

42.72

529

43.19

1,109

Secondary +

57.58

356

58.82

238

58.08

594

Education

4.3.5. Knowledge of Prevention of Mother-to-Child Transmission of HIV Knowledge of ways in which HIV can be transmitted from mother to child and eliminating the risk of transmission using antiretroviral drugs are critical to eliminating mother-to-child transmission (eMTCT) of HIV. To assess this knowledge, we asked respondents if the virus that causes AIDS can be transmitted from a mother to a child during pregnancy, delivery, and while breastfeeding. Figure 4 shows that, overall, 90.2 per cent of women and 83.1 per cent of men know that HIV can be transmitted by breastfeeding. Proportions of women who know that HIV can be transmitted during pregnancy and delivery are 50.8 per cent and 92.5 per cent respectively. In men these proportions are 46.2 per cent and 92.6per cent respectively. There are no marked differences in MTCT knowledge among women and men by background characteristics such as age, educational level and marital status. Respondents were further asked whether HIV transmission from mother to child could be prevented by antiretroviral treatment. Here 81 per cent of women and 74 per cent of men knew that the risk of MTCT could be reduced.

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Figure 4: Knowledge of prevention of mother to child transmission

Focus group participants reported that they had received information about MTCT mainly from health workers. They also reported that pregnant women were encouraged to attend ANC regularly and discouraged from delivery from home without attendance of a qualified health worker as articulated in the voice below: We know the dangers of AIDS especially for pregnant women and their children. Women who are pregnant are told that they should go to the health centre to give birth (FGD, Men, 15-59, Kasese).

4.3.6. Knowledge about antiretroviral treatment During the survey, men and women were asked if they knew about drugs that can be prescribed to people with HIV to enable them to live longer. Overall, knowledge that there are drugs to help people living with HIV (PLHIV) live longer is high. Here 97 per cent of men and women, each reported to know of drugs that can help people live with HIV longer. Respondents were also asked to name the drug or drugs they knew about. A high proportion of both men (76.3%) and women (73.7%) mentioned ARVs. More than half of the respondents also mentioned Septrine as a drug that could help PLHIV live longer.

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Table 8: Knowledge of drug treatments for AIDS

Male

Female

# men

# Women

Yes

97.40

1,038

96.67

932

2.60

3.33

ARVs

76.3

772

73.7

664

Cotrimoxazole

54.8

554

64.3

580

Traditional medicine

1.58

1.89

Other drugs

1.3

2.0

Don’t know any drug

2.69

3.33

Yes

95.3

716

96.5

613

4.7

3.5

Know drug for people with HIV

Which drugs do you know

Do you know source of ARVs

4.3.7. Expanded knowledge about ARVs The Uganda AIDS indicator survey (MoH, 2012) defines ‘expanded knowledge about ARVs’ as being able to correctly agree or disagree with five statements regarding anti-retroviral therapy, namely: 1. ARVs do not cure AIDS 2. People taking ARVs can still transmit the virus that causes HIV 3. ARVs must be taken by a PLHIV for the rest of life 4. People living with HIV should not wait until they are sick to seek care 5. Failing to take the ARVs correctly (as prescribed) makes the HIV virus resistant Overall, 46 per cent of women and 44 per cent of men demonstrated comprehensive or expanded knowledge of anti-retroviral therapy, defined as correct knowledge on all the five statements above. Two-thirds of women (66.2%) and 63.5 per cent of men agreed that ARVs do not cure AIDS. In addition, 71.8 per cent of women and 69.3 per cent of men agreed that people taking ARVs can still transmit the virus that causes AIDS. A high proportion of men (96.2%) and women (96.8%) were also aware that failing to take ARVs correctly can make HIV resistant. The percentage of women who know that ARVs must be taken for life and that people who are living with HIV should not wait until they are sick to seek care is 91.8 per cent and 88.3 per cent, respectively. Among men, the percentage is 90.8 per cent and 87.5 per cent respectively.

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Figure 5: Expanded Knowledge of ARVs

4.3.8. Knowledge about Source of ARVS Among those who knew about ARVs, 96 per cent of women and 94 per cent of men knew of a source of ARVs (Table 9). Government health centres and hospitals were the most frequently mentioned sources of ARVs by men and women, 55.1 and 46.3 per cent, respectively. Table 9: Knowledge of source of ARV drugs

Source of ARV

Men

Female

Total

# women

# men

# overall

Government hospital

46.2

426

46.4

386

46.3

812

Government health centre

54.5

502

55.9

465

55.1

967

Other public

0.65

0.84

0.74

Private hospital/clinic

6.4

5.4

5.9

104

Pharmacy/drug shop

0.43

0.1

0.3

Private doctor/nurse/midwife

0.1

.0.0

0.1

Outreach/mobile clinic

2.1

2.4

2.2

19.09

176

15.4

128

17.3

304

PUBLIC SECTOR

PRIVATE/NGO MEDICAL SECTOR

NGO

Qualitative findings further revealed that respondents had sufficient knowledge of the sources of antiretroviral treatment. The major sources reported were hospitals and health centres. …people can get treatment at ART centres here in Wakiso district. These are accessible and open to all people who have tested HIV positive. (IDI, DHO, Wakiso district) These days we know that there are drugs you can take to prolong life and many people here are on these drugs, they get them from Kilembe hospital. (FGD, Men, 15-59, Kasese)

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

4.3.9. Source of HIV and AIDS information Analysis was done to determine the percentage of respondents receiving AIDS information and education from the different channels of communication. Respondents were allowed to cite as many channels as possible. As a follow up, respondents who cited the channels of information were asked to name the most important message they learned from the main source of AIDS information. The top five (5) channels of communication cited by the respondents include radio (77.5%), health workers (77.7%), friends (23%), community leaders (20.8%), and peers (20.4%). The percentage of respondents citing the different channels as the main source of learning for most of the AIDS information is 42.5 per cent for radio and 40 per cent for health workers. Table 10: Main channels of communication for HIV and AIDS information Female % respondents receiving AIDS information and education from the channel **

Male

% respondents citing the channel as the source of learning for most of the AIDS information

% respondents receiving AIDS information and education from the channel **

% respondents citing the channel as the source of learning for most of the AIDS information

Radio

75.2

37.5

79.6

47.0

Health Workers

81.2

45.7

74.5

34.8

Friends

24.3

2.2

22.0

1.6

Teachers

19.0

4.8

17.5

3.2

Television

13.4

1.5

15.9

2.1

Newspapers/Magazines

5.9

0.2

12.3

1.4

Family

12.9

2.7

14.8

1.9

Peers

16.6

0.0

21.0

0.0

community leaders

20.0

1.4

21.4

2.5

Religious Leaders

16.7

0.8

16.5

0.9

Drama

8.9

0.9

9.7

0.8

Posters

1.0

0.0

2.1

0.0

Billboards

1.4

0.1

2.4

0.1

Film

5.3

0.3

7.2

0.8

Brochures

0.5

0.1

1.8

0.2

Others

9.3

1.8

9.8

3.2

Focus group discussions elicited similar sources of HIV and AIDS information. Radio and health workers were cited as the most common source of AIDS information, as reflected in voice below: We get information from health workers at Rhino camp health centre (FGD, Women, 25-59, Arua) From the NGOs such as TASO, who sometimes come here to test people for HIV (FGD, Women, 25-59, Arua) We also get information through radios. If you find a programme on radio about HIV/AIDS and gets interested, you sit and listen to what they teach (FGD, Women, 15-24, Wakiso)

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Most important messages learnt Respondents were asked to state the most important message learnt from the main source of information. The most important messages cited concerned condom use (31.9%), being faithful to one sexual partner (18.8%), abstaining from sex (15.8%), and need to be tested for HIV (13.6%). These messages reflect the primacy given to HIV prevention, as shown in Table 11 below. Table 11: Most important messages learnt Most important message learned from main source of AIDS information

Use condoms

31.9

Faithful to one Partner

18.8

Abstain from sex

15.8

Get tested for HIV

13.6

Limit Sex to one Partner/Stay Faithful to one Partner

3.9

Others (include, follow ABCs, AIDS is a killers, ARVs are available)

14.4

The importance given to HIV prevention is corroborated by qualitative data. Some of the most important messages which respondents reported to have learned about HIV and AIDs were in the domains of limiting multiple sexual partners, having HCT, and PMTCT as illustrated below: The most important message from the radio is that we should limit sexual partners. This an important message because if one limits sexual partners, they reduce chances of getting AIDS” (FGD, Women, Arua) Health workers tell us that pregnant mothers should always check their blood for HIV, and ensure that they give birth from the health centre to avoid complications and possibility of passing HIV to their babies. This information is important for pregnant mothers to ensure their health and the baby’s health during and after pregnancy (FGD, Women, Arua)

4.4.

HIV and AIDS related attitudes

4.4.1. Stigma Stigma and discrimination towards people living with HIV (PLHIV) has implications for HIV prevention, care and treatment. For example, stigma and discrimination affects people’s willingness to be tested for HIV and their adherence to ART (Genberg et al., 2008; Neuman & Obermeyer, 2013; Skinner & Mfecane, 2004). During the survey, respondents who had heard of AIDS were asked if: 1. They would be willing to care for a relative infected with HIV and AIDS, 2. They would be willing to buy fresh vegetables from a market vendor who was infected with HIV and AIDS, 3. They thought a female teacher who has the AIDS virus but is not sick should be allowed to continue teaching, and 4. They would want to keep a family member’s HIV status secret.

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Overall, women (47.9%) were more likely to express accepting attitudes on all four indicators above when compared with men (41.1%). Almost the same proportion of women (96.9%) and men (97%) were more likely to be willing to take care of a family member with HIV at home. However, slightly more men than women reported that they would buy fresh vegetables from a shopkeeper who has AIDS (91.3 % compared to 88.4%). Women on the other hand were more likely than men not to want to keep secret a family member’s infection with HIV (58.8 % versus 53.4%). These findings show that, overall, the fishing communities have a reasonable level of accepting attitudes towards persons living with HIV. The proportion of respondents expressing positive attitudes in reference to stigma and discrimination was highest among those in long term relationships including among the married and/or those cohabiting, and those with secondary or higher education (Table12).

Female Percentage who say that:

Would buy fresh vegetables from shopkeeper who has the AIDS virus

Would not want to keep secret that a family member got infected with the AIDS virus

% expressing accepting attitudes on all four indicators

Are willing to care for a family member with the AIDS virus in the respondent’s home

Would buy fresh vegetables from shopkeeper who has the AIDS virus

Would not want to keep secret that a family member got infected with the AIDS virus

% expressing accepting attitudes on all four indicators

# women

Are willing to care for a family member with the AIDS virus in the respondent’s home

Male Percentage who say that:

# men

Background characteristic

Table 12: Accepting attitudes toward those living with HIV and AIDS

Age 15-24

95.5

91.0

53.21

36.71

357

95.3

87.7

59.24

50.32

357

25-39

97.1

92.0

59.30

48.00

474

97.4

89.0

58.45

47.60

474

40-59

97.6

89.4

57.00

42.50

207

97.1

85.5

57.14

46.03

207

Total , 15-59

96.6

91.1

53.38

41.10

1038

96.6

89.0

58.77

47.91

1038

Married

97.0

92.2

51.86

41.46

626

96.7

87.8

58.54

45.01

626

Single

95.7

90.1

71.43

57.14

322

95.3

88.4

68.66

59.70

322

Divorced/ separated

97.2

87.3

57.75

38.03

97.4

89.7

59.48

51.28

Widow/ widower

100.00

89.5

31.58

98.4

84.4

46.88

40.63

No education

91.49

95.74

61.29

41.49

96.77

85.71

59.35

44.52

154

Primary

97.05

88.97

53.20

39.76

580

97.15

86.93

57.01

46.50

528

Secondary +

98.31

94.10

51.69

43.26

356

96.20

92.83

62.03

52.94

237

Marital status

Education

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

There are also notable district variations in accepting attitudes towards people living with HIV/AIDS, with Arua scoring the lowest in all four indicators for both men and women. Figure 6: Proportion of women and men who express accepting attitudes towards PLHIV by district

Figure 7: Proportion of women and men who express accepting attitudes towards PLHIV by age

4.4.2. Attitudes toward negotiating safer sex Knowledge about HIV transmission and prevention is undermined by a sense of powerlessness to negotiate for safer sex. To assess the ability of women to negotiate safer sex with their partners, participants were asked whether they thought that a wife is justified in refusing to have sexual intercourse with her husband if she knows he has sex with other women, or asking that he use a condom if she knows he has a sexually transmitted infection (STI).

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

As shown in Table 13, the results show that the proportion of women and men who believe that, if a husband has an STI, his wife is justified in refusing to have sex with him was 66.4 and 71 per cent, respectively. The proportion of women and men who believe that, if a husband has an STI, his wife is justified in asking that the husband use a condom was 89.1 and 87.7 per cent, respectively. Table 13: Attitudes towards negotiating safer sex

IF HUSBAND HAS AN STI, WOMEN ARE JUSTIFIED TO:

Male (N=1039)

Female (N=932)

Refuse sex:

71.0

66.38

Propose condom use

87.67

89.14

Refuse sex or propose condom use

92.27

91.72

A high proportion of women also reported that they were able to ask their spouse/partner to use a condom if they wanted them to (87%), or say no to their spouse/partner if they did not want sexual intercourse (85%). 4.4.3. Perceived norms about abstinence and faithfulness The social norms theory predicts that widely held misperceptions may encourage risky behaviour in a misguided attempt to conform to perceived norms. Respondents were asked if they believed that most young men/women abstain from sex until they are married, and if they believed that most married men/women they know only have sexual intercourse with their wives/husbands. Figure 7 shows that people in fishing community perceive that young men and women do not wait until marriage to have sex, and that multiple partnerships, are the norm in fishing communities, for both men and women. Figure 8: Perceived norms

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

4.4.4. Perceptions about condom use education for children aged 12-14 During the study, respondents were asked whether they thought that children aged 12-14 should be taught about using a condom to avoid getting AIDS. Nearly seven in ten adults agree that children aged 12-14 years should be taught about using condoms to avoid HIV (80% women and 66% of men).

4.5.

HIV Related Sexual Behaviours and Practices Heterosexual contact remains the predominant mode of HIV transmission in Uganda. And age at sexual debut has been shown to correlate with the risk of exposure to HIV transmission. In addition, risk taking sexual behaviours such as multiple sexual partnerships, unprotected sex, and engaging in transactional sex also put people at risk of HIV transmission. We elicited responses regarding sexual behaviours and practices. The key HIV related behavioural variables that were examined include age at sexual debut, condom use at first sexual intercourse, primary and secondary abstinence, multiple sexual partnerships, use of condoms during most recent sexual intercourse with each type of partner (casual, regular or spouse), transactional sex, and crossgenerational sex. Primary abstinence is defined as the proportion of never-married youth (aged 1524) who have never had sex. Secondary abstinence was defined as the proportion of never married youth who have ever had sex but not in the past 12 months. Cross-generational sex was defined as non-spousal sex by a woman aged 15-19 years with a man 10 or more years older.

4.5.1. Primary and secondary Abstinence About 31 per cent of never married youths, 15-24 years reported never having had intercourse (primary abstainers). A higher proportion of female youths reported never having had intercourse compared to male youths (38.9 % vs. 24.5 %). Among sexually experienced youth, 18.8 per cent reported that they had not had sex in the 12 months preceding the study (secondary abstainers). More men (19.4%) reported secondary abstinence compared to women (17.7%). Table 14: Primary and secondary Abstinence

Age Group

Primary Abstinence: Never-married youths, aged 15-24 years, that have never had sex Female

15-24

Male

38.9

185

24.5

253

Secondary Abstinence: Sexually experienced respondents aged 15-24 years, that did not have sex in the past 12 months Female 15-24

Male

17.7

113

19.4

191

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

4.5.2. Age at sexual initiation Previous studies have demonstrated that early initiation of sex has increased risk of HIV infection. An effort was therefore made to establish the age of sexual debut for people in fishing communities. The mean age at first sexual intercourse was 15.4 years for women (Median 16; SD ±5.1 years) and 16.2 years for men (Median 17; SD ±5.4 years). Overall, the results show that women initiate sex earlier than men do. Nearly a third of women (33.5%) and more than a quarter of men (28.1%) aged 15–59 had heterosexual intercourse before they were 16 years (Table 16). Table 15: Age at sexual debut and condom use at fist sex

Female

Male

Total

<16 years

33.5

287

28.1

274

30.7

561

≥16 years

66.5

569

71.9

700

69.3

1269

Yes

17.68

148

17.36

168

17.51

316

82.32

689

82.64

800

82.49

1489

Age at first sex (yr)

Condom use at first sex

4.5.3. Condom use at sexual debut Condom use at first sex reduces the risk of both HIV acquisition and pregnancy among young girls. Analysis was done to determine the percentage of respondents who used a condom the first time they had sex. Only, 17.5 per cent of the respondents (17.4% of men and 17.7% women) reported condom use at first sexual intercourse. 4.5.4. Multiple Sexual Partnerships Sexual networks contribute to the spread of HIV infection. Therefore, assessment of the number of sexual partners is important because having many sexual partners widens sexual network and increases the risk of HIV transmission. We asked all sexually active respondents (n=1613) about the number of partners they had had sex with in the past year, past six months and past 30 days (Table 18). Findings suggest that a considerable proportion of people in fishing communities, both men and women, engage in sex with multiple partners. Among all respondents aged 15-59 years, 45.8 per cent reported having had two or more sexual partners in the 12 months preceding the survey. More men (59%) compared to women (30%) reported having had two or more sexual partners. Further analysis indicates that seven per cent of women and 19 per cent of men had sex with five and more partners in the 12 months preceding the survey (Table 18). These findings show that multiple sexual partnerships are more common in men than in women, and suggest the presence of sex work in fishing communities.

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Table 16: Number of sexual partners in the last 12 months

Female

Male

Total

70.14

512

41.11

363

54.25

875

2-4

22.88

167

39.98

353

32.24

520

5-49

5.9

18.23

161

12.64

204

≥50

1.10

0.68

0.87

81.95

522

59.15

462

69.39

984

2-4

13.97

34.44

269

25.25

358

5-49

3.14

5.88

4.8

≥50

0.94

0.26

0.56

91.89

544

78.03

540

84.42

1084

2-4

6.08

20.38

141

13.79

177

≥5

2.0

12.0

1.6

11.0

1.8

23.0

# of sexual partners in the last 12 months

# of sexual partners in the last 6 months

# of sexual partners in the last month

Lifetime sexual partners The mean number of lifetime sexual partners among those who have ever had sex is approximately seven for women (Median3; SD ± 13.9 years) and 15 for men (Median7; SD ± 22.9 years); further indicating that men are much more likely than women to engage in multiple sexual partnerships. Table 17: Lifetime sexual partners

Female

Male

Total

<10

83.55

716

57.54

561

69.71

1277

10-19

7.58

18.87

184

13.59

249

20-49

4.20

13.13

128

8.95

164

50+

2.33

8.72

5.73

105

Don’t remember /No response

2.33

1.74

2.02

TOTAL No. of life time partners

4.5.5. High Risk Sexual Intercourse High risk sex is yet another risk factor for HIV transmission. High risk sex is defined as having sex with a non-marital partner (Ministry of Health, 2012; UBOS & ICF International Inc, 2012). The results show that, among respondents aged 15-59 who were sexually active in the preceding 12 months, 45.5% of women and 65 % of men engaged in high risk sex. About 43.8 per cent of women and 47.1 per cent of men had had sex with between two and four casual partners in the last 12 months. In addition, 71.9 and 55 per cent of women and men had at least one regular partner in the same period (Table 18).

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Table 18: High risk sex in the past 12 months

Women Percentage who had sex with

Men Percentage who had sex with

Casual Partner (n=121)

Regular Partner (n=295)

Casual Partner (n=312)

Regular Partner(n=454)

32.2

71.9

24.4

55.3

2-4

43.8

27.5

47.1

38.1

5-49

17.3

0.6

26.9

6.3

â&#x2030;Ľ50

6.6

0.0

1.6

0.2

Last 12 months

FGDs and IDIs revealed a number of reasons why people in fishing communities engage in multiple sexual partnerships. These included: poverty, spousal neglect, polygamy and general affinity for risky behaviour as articulated below: Polygamy also causes women to have multiple partners. A man may have over five wives and cannot fulfil all their sexual desires. In such a circumstance, a woman who cannot wait for the same man resorts to have other partners outside the marriage to get sexual satisfaction. (FGD, Women, Arua) Women decide to have many sexual partners to get money. Many do it here at the landing site. (FGD, Women, Arua). It is natural that some men cannot just control their sexual libido, so that makes them to have various partners to fulfil their sexual desires. (FGD, Women, Arua) 4.5.6. Cross-generational sex Analysis was done to determine the percentage of women aged 15-19 years who have had sexual intercourse with a non-marital partner who was 10 years or older than themselves in the 12 months before the study. No women aged 15-19 reported sex with a man 10 years or older than themselves in the 12 months prior to the survey. Nonetheless, qualitative data indicates cross-generational sex is a common phenomenon in fishing communities. Cross generation sex is primarily driven by the need for material gains among young girls. Some people usually come here and normally use their money in luring young girls in falling in love with them, and you know many girls here have gotten infected with the virus in that way. (Women FGD, 15-24, Apac) The ratio of boys to girls here is high. There are more boys than girls and girls are being shared. Even older men go for the same young girls (FGD, Men, 15-59, Kasese)

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

4.5.7. Condom Use Practices The proportion of sexually active respondents who reported condom use at the last sexual intercourse was 25.5 per cent. This indicates that overall, 74.5 per cent of both men and women had had unprotected sexual intercourse on the last occasion they had sex. Men (29.2%) were more likely to report condom use at last sexual intercourse compared to women (21.2%). Respondents reporting multiple sexual partners were more likely to use condoms at the last sexual encounter compared to those without multiple partners (37% compared to 18%). Condom use was also associated with marital status (p=0.000), education level (p=0.007), district of residence (P = 0.015), and knowing that it is possible to obtain a condom if one wants (P = 0.00). With respect to education, participants with secondary or higher education were more likely to report condom use at the last sexual encounter (31%) compared to those with no formal education (21%) or primary level education (24%). Similarly, condom use at last sexual encounter was higher among those who used who said that they would get themselves a condom if they wanted to, compared to those who said they wouldnâ&#x20AC;&#x2122;t (28% vs. 3%). The proportion of participants who used condoms at the last sexual encounters was also highest in Arua district (29%), and lowest in Rakai district (19%).

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Table 19: Factors associated with condom use at last sex among participants aged 15-59

MULTIPLE SEXUAL PARTNERS IN THE LAST 12 MONTHS

Condom use at last sex Yes

Yes

36.4

63.6

17.56

82.4

Male

29.2

70.8

Female

21.2

78.8

15-24

34.9

65.1

15-59

25.4

74.6

Yes

27.7

72.3

3.3

96.7

Married

17.2

82.8

In cohabiting relationship

22.7

77.3

In non-cohabiting relationship

47.3

52.8

Single, not in a relationship

41.4

58.6

Divorced/separated

31.2

68.8

Widow/widower

17.1

82.9

No education

21.1

79.0

Primary

23.6

76.4

Secondary +

30.9

69.1

Apac

23..1

76.9

Arua

29.0

70.9

Kasese

23.9

76.1

Masaka

29.8

70.2

Rakai

18.9

81.2

Wakiso

27.9

72.1

P-value*

SEX 0.000

AGE (YEARS)

IF YOU WANTED TO, COULD YOU YOURSELF GET A CONDOM 0.000

MARITAL STATUS

0.000

EDUCATION

0.007

DISTRICT

0.015

4.5.8. Condom use with various partners Evidence suggests that when used correctly and consistently, condoms could protect against HIV infection. During the study, respondents were asked whether they used condoms all the time or some of the time. Overall, consistent condom use is higher among casual partners followed by regular partners but lowest among those in marriage. Nearly six in every ten men (55.8%) and five in every ten women (47.2%) reported consistent condom use with a casual partner (Table 20). Consistent condom use with regular partners was reported by only 26 per cent of men and 24 per cent of women.

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Table 20: Condom use by partner type in the last 12 months

Women Partner type

Men

Every time

Sometimes

Never

Every time

Sometimes

Never

Casual Partner

47.2

32.5

20.3

55.8

21.1

23.1

Regular partner

23.8

36.4

39.7

25.8

39.1

35.1

Spouse

3.3

18.7

2.2

17.00

80.8

Participants reported that it is not always easy for both men and women to use condoms with all partners all the time despite almost universal awareness about the importance of consistent condom use in HIV prevention. Data from FGDs and IDIs also provide some insights into the quantitative findings. When asked whether it is possible for people to use condoms consistently, some participants felt it was indeed possible and necessary to use condoms all the time, in order to protect oneself from the risk of HIV infection: “Yes, it is possible. On our landing site, people have increased condoms use because we have prostitutes who come here, but they have to register first before you start that work, whenever they go to the LCI to register, you are given a packet of condoms which means they use them. Those you see arrested are those who refuse using them” (FGD, Women, Masaka district)

Some participants expressed a personal responsibility to use condoms to protect their health and the health of their partners. For example, one man reported: “I take my own precautionary measures [always using condoms]”.

Some participants reported using condoms to prevent acquisition and/or transmission of STI. However, most participants did not think consistent condom use is possible. Dissatisfaction with condoms, women’s belief that condom use may signal mistrust, concerns about the safety of condoms, were cited as some of the factors contributing to inconsistent condom use. These factors are discussed in turn below:

Condoms interfere with sexual pleasure: during focus groups, some participants indicated that the use of condoms during vaginal intercourse significantly reduced sexual pleasure. They generally believed that unprotected intercourse was more pleasurable than protected intercourse, and indicated that condoms were a barrier to spontaneity, passion and intimacy. “There are people who don’t want to use condoms saying; having sex with a condom is “like eating sweets in their wrappers... meaning that when they use a condom during sex they don’t enjoy (FGD, Women, Wakiso district) They think that when they use condoms, they won’t enjoy. Therefore, they need to be educated that even when you use it, you will still enjoy the same as that one without. (FGD, men, Masaka district)

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Alcohol abuse: Qualitative findings illustrated that when men and women were under the influence of alcohol there was a higher likelihood of unprotected sex. Participants’ narratives reveal that some men and women consume a lot of alcohol before sex, an act that impairs their judgement, affects their decision-making and thus may cause them not to use condoms even when they have them. As one woman explained: Yes, one or two times it [unprotected sex] happened … Only when he is drunk such things happen … He troubles me by asking to do so [have sex] … no condom in such situations(FGD, women, Masaka)

Similar sentiments are reflected in the voices below: “… young people claim they cannot enjoy fully …” (FGD, Men, Kasese)

“Many bar owners bring prostitutes to work in their bars and these women also offer sex on top of beer so when a man is drunk he may not think about getting a condom” (FGD, Men, Kasese)

Concerns about the safety of condoms: Wrong perceptions about the safety and efficacy of condoms were also reported to contribute to inconsistent use. Some fishermen believed that condoms do not effectively prevent HIV as the virus is perceived to be deliberately manufactured together with the condom and lives with the lubricants, while some women suggested that condoms lead to cancer of the womb or other reproductive health problems. “And some people say that it is not a 100 per cent safe, but it is ninety nine per cent. The one per cent which the condom is short of can even make you get infected of HIV/AIDS” (FGD, Women, Wakiso). “Some people do say condom can remain in a woman so they are afraid of using because some people do not know how to use it” (FGD, Women, Apac). We suspect that fluid in the condoms is also an AIDS disease, you open a condom and you wonder what the use of the fluid in the condom is. Some also say that fluid in the condom reduces man power in long run. (FGD, Men, Masaka) Some of them say when you use condom you can get cancer. (FGD, women, Apac)

Unplanned sex: Some study participants also reported that their sexual encounters, especially with casual partners, were not planned and they did not always carry condoms. One man said: When my sexual feelings become stronger I go to a shop or health facility and get some condoms … but if I meet them [sex workers] suddenly, where can I get condoms? In such situations, I did not use condoms (FGD, men, Apac)

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Fatalistic attitudes and normalisation of HIV: It was a recurring theme that the fisher folk had a fatalistic approach towards life, which contributed to non-condom use. Discussants revealed that there were those who were indifferent and do not understand why HIV and AIDS is such a big deal. They consider it a disease just like any other. Some participants explained that considering the risks involved when fishing in the deep waters, the chances of one dying while fishing are more than dying from AIDS, thus making HIV and AIDS least of their worries. Some fisher folks also believed that even “if one does not get infected with HIV and died of AIDS, eventually we will all die someday, through other causes such as accidents. “People here have I don’t care attitude, saying even if they use condoms, one day they will after all die” (FGD, Women, Arua). Some people think they are immune to HIV/AIDS infection” (FGD, Women, Kasese).

Fear of marital discord: Some participants also reported that consistent condom use in the context of marital relationship was not possible. Both men and women believed that condom use may signal mistrust, and alluded to unprotected sex as a symbolic way to express love. In particular, some indicated that condoms were only meant for casual sexual partners. “The women feel it is embarrassing for a woman to demand her husband to use condom when she suspects that he is having sex with other partners. More so, those who demand are often assaulted because the men feel the women are insubordinate to them” (FGD, Women, Arua).

Trust in transactional sexual relationships: Some participants reported the level of trust in some longer-term transactional sexual relationships can mean that condom use is not insisted upon. In addition, some women also reported limited ability to negotiate for safe sex in the context of transactional encounters, as revealed below: Women in fishing communities are not likely to negotiate condom use because if they insist, they fear to be given less fish, food or money, or to be rejected completely.

On the other hand, some men reported that they expected “full” sexual pleasure during casual sex, and thus were disinclined toward condom use with their casual partners, including sex workers. 4.5.9. Initiating the discussion on condom use in a relationship Both men and women were asked about who initiated condom use in the relationship. About 74 per cent of women and men each reported that they had initiated condom use with their partners as indicated in Table 21. Five per cent of the women and men reported to have used a condom, following a suggestion by a health worker or counsellor.

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Table 21: Initiating discussion on condom use

Women

Men

Per cent

Number

Per cent

Number

I suggested condom use myself

76.43

120

75.78

194

My partner suggested condom use

19.59

21.58

Condom use suggested by counsellor/health worker

6.12

5.96

Others

2.15

3.42

4.5.10.

Transactional Sex Transactional sex is defined as a relationship that involves the exchange of money or material goods for sex (MacPherson et al., 2012; Wamoyi, Fenwick, Urassa, Zaba, & Stones, 2011).Transactional sex is associated with high risk of contracting HIV and other sexually transmitted infections due to compromised power relations (Bobashev, Zule, Osilla, Kline, & Wechsberg, 2009; Chatterji, Murray, London, & Anglewicz, 2005; MacPherson et al., 2012; Norris, Kitali, & Worby, 2009). For example women may be fearful of refusing unprotected sex with partners on whom they rely for material support (Wamoyi et al., 2011). During the survey, respondents who had had sex in the previous 12 months were asked about giving or receiving money, favours, or gifts in exchange for sex. Table 22 shows that over 33.8 per cent of men and 23.8 per cent of women who had sex in the past 12 months reported engaging in transactional sex. The proportion who engaged in transactional

sex in the past 12 months was highest among young adults aged 15-24 for both men and women. Among both men and women, those who were widowed and divorced/separated were more likely to engage in transactional sex (64% and 48%, respectively). Those who are currently married are least likely to have engaged in transactional sex. The proportion of women and men who engaged in transactional sex is highest in fishing communities in Rakai (49.8%), followed by Masaka (48.7 %). Men (42.5%) and women (27.5%) without any formal education are most likely to engage in transactional sex. Data from FGD and IDI also provide some insights into the reasons why women in fishing communities engage in transactional sex. Motivations for engagement in transactional sex were mediated by economic need, social positions and gender roles, and relations of both men and women working within the fishing industry. One of the more common themes for women’s participation in transactional sex was poverty or need for financial need/support in the form of money and/or goods because of financial hardship, and desire for luxury and/or status. Phrases like “using what you have to get what you want” were commonly used by women to justify transactional sex encounters.

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

It’s because of poverty which makes or drives you to do what you will regret. You find a man is sick but has money or rich, so you just decide to love him because of poverty. Even these prostitutes it’s because of poverty but they wouldn’t do it but because they have children and also if the husband died or they separated (FGD, women, Masaka). Table 22: Transactional Sex by Background characteristics

Women Gave or received money, gifts, or favours (%)

15-24 25-39

Men

Gave or received money, gifts, or favours

28.0

261

39.2

258

22.5

382

36.3

449

Age

40-59

12.6

18.2

176

Total 15-59

23.3

730

33.5

883

Married

15.9

498

27.4

605

Single

40.0

135

42.1

214

Divorced/separated

34.7

62.3

Widow/widower

47.6

63.6

No education

27.5

109

42.5

Primary

23.4

432

36.6

494

Secondary +

21.6

181

26.1

303

Marital status

Education

District Apac

5.2

12.8

125

Arua

0.9

109

14.1

142

Kasese

19.4

108

19.7

152

Masaka

40.0

140

56.1

164

Rakai

39.2

153

60.4

154

Wakiso

19.4

142

30.8

146

4.5.11.

Condom use during transactional sex About 63.5 per cent of women aged 15-59 reported that they had used a condom the last time they engaged in transactional sex, and 41.6 per cent reported using condoms each time they engaged in transactional sex. Among men, 55.9 per cent reported using a condom the last time they had paid for sex, and 43.7 per cent reported using condoms each time they paid for sex. Discussions with participants revealed that some women find it hard to negotiate for condom use especially in context of transactional sex. Participants revealed that in cases of transactional sex, men were often unwilling to use a condom once they have paid for sex. It was revealed that some clients are often willing to pay more money for ‘condom-less’ sex, and women find such offers difficult to resist. HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

In addition to that, women here are faced with unemployment and this has made them to engage in prostitution because with fishermen they pay higher for unprotected sex than protected sex so you find out that women engage in more of unprotected sex to earn higher from it which is very dangerous. (IDI, Community Leader, Rakai District)

4.6.

Alcohol use during Sex Alcohol use has been linked to risk disinhibition making people more likely to engage in risky sexual behaviour (Grellier et al., 2004; Wolff, Busza, Bufumbo, & Whitworth, 2006). To investigate the extent of alcohol use and sexual activity, respondents were asked whether they or their partner drank alcohol the last time they had sex and if so, whether they or their partner or both were drunk. About one-quarter of both women and men (24.8%) who had sex in the 12 months before the survey said that either they or their sexual partners had taken alcohol the last time they had sex. More men reported that they or their partner had taken alcohol compared to women (26.7% vs. 22.6%). About 30 per cent of the women and 29 per cent of men reported that they and their partners were both drunk, while 51 per cent of women and 13 per cent of men reported that only their sexual partner was drunk during the last time they had sex. Findings from FGDs indicate that men and women in fishing communities consume a lot of alcohol before sex, increasing their risk of not using condoms despite having them. “I think HIV is spreading rapidly, largely because women take a lot of alcohol, even more than men. Therefore, they end up having sex, under the influence of alcohol [when they are extremely drunk]. Therefore, a man can do whatever he wants, without their consent and knowledge. It is always better that a woman helps the man wear the condom—because men lose all their senses at that point [just before sex]”

4.7.

HIV Risk Perception Perceived vulnerability is critical to an individual’s precautionary behaviour (Gerrard et al., 1996). High perceived risk is associated with low risk-taking behaviours and vice versa.

If, for instance, people

feel that they may be at a higher risk of HIV infection, such people may feel inclined towards those approaches that can best reduce their risk. However, if people don’t feel at risk of HIV, they are less likely to behave cautiously. The study established the extent to which people, both men and women perceived themselves to be at risk of HIV infection. In response to the question, “Are you aware that people in fishing communities are a high HIV-risk group?”, 97 per cent of both men and women responded in the affirmative, suggesting high levels of awareness among respondents that fishing communities are at a high risk of HIV infection. Asked, why they considered fishing communities to be at high risk HIV risk, FGD participants pointed to high mobility in the community, a culture of sharing women, widespread alcohol use, and the widespread

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

prevalence of HIV high-risk behaviours, including transactional sex, unsafe sex and multiple partnerships. Notably, most respondents perceived that all the people were at risk of HIV, noting that even married people were at risk of infection especially those engaging in extramarital relationships. Further, some participants perceived women to be at greater risk, noting that the risk was related mainly to being involved in transactional sex. Women are at high risk. Some women have different men because of situation (Poverty) so she thinks having different guys; she will get money for up keep. (Masaka, Lambu women)

With regard to self-perception of risk of HIV, 68 per cent of the respondents (63% of men and 68 % of women) perceived themselves to be at a high risk of HIV infection. Some of the reasons for perceived risk of HIV include inconsistent condom use and multiple sexual partnerships. Table 23: Reasons for perceived risk of HIV by gender

Women

Men

Per cent

Number

Per cent

Number

I usually engage in sex without using a condom

37.0

230

36.4

238

I have had many sexual partners whose HIV status I am not aware of

9.34

20.2

132

I have multiple partners, some of whom cannot be trusted

6.1

11.9

Others

47.5

295

31.5

206

Data from FGD and IDI also provided insights into the quantitative findings. Participants reported that either having multiple sexual partners themselves or due to their partners being involved in multiple sexual relationships was a reason for their vulnerability to HIV. Some of us have very many sexual partners. Having many sexual partners does increase on oneâ&#x20AC;&#x2122;s chances of getting the virus. Because you may love six partners, one stays at Kigungu, the other at Mukono and one at Masaka but when you do not know how these people live in your absence. They may be living a sexually immoral life in your absence, (FGD. Male, Wakiso)

In addition to their own assessment of personal risk, participants were further asked whether they thought their partners would be at risk of HIV. Here 65.4 per cent of men and 74.2 per cent of women believed that their partners were at risk of HIV infection, citing unfaithfulness (39.3%), and that their sexual partners normally have sex with other people (18.3%) as shown in Table 24 below.

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Table 24: Reasons why partner is at risk of HIV

Reasons why partner is at risk of HIV Male (n=655)

Female (n=649)

Total (n=1304)

Partner has sex with other partners

12.7

18.3

Partner not trustworthy

40.2

39.3

Partner does not use condoms

18.9

16.0

Because I am HIV positive

11.5

12.3

Other

16.8

14.0

Reason

4.8. Self-reported prevalence of sexually transmitted infections (STIs) Information about the prevalence of STIs is not only useful as a marker of unprotected sexual intercourse but also because STI infection is a co-factor in HIV transmission (Galvin & Cohen, 2004; Plummer & Ndinya-Achola, 1990). During the study, all respondents who ever had sex were asked if they had had an STI or symptoms of an STI (including abnormal genital discharge and genital sore) in the 12 months preceding the survey. Women (41 %) were more likely than men (29%) to report ever having had an STI or having experienced symptoms perceived to be an STI in the last 12 months preceding the survey. Among women, 41 per cent reported that they had an STI; 29 per cent had an abnormal discharge; and 33 per cent had had a genital sore. Among men, 29 per cent reported that they had an STI; 21 per cent had an abnormal discharge; and 23 per cent had a genital sore. Among both women and men, the proportion of participants who reported ever having had an STI or symptoms perceived to be an STI in the last 12 months was highest among the 25-29 age cohort (48.7 % of women and 34.2% of men), and among fishing communities in Masaka (53.6% of women and 41.7 % of men) and Wakiso (54% women and 40% of men). There were also variations among women in the reported prevalence of STI by marital status and education. Women in marital relationships and men who were divorced or separated reported the highest prevalence of STI at 44 per cent and 34 per cent respectively. Women with no education (31%) reported the lowest prevalence of STIs or STI symptoms. Conversely, men with secondary education or higher education reported the lowest prevalence of STIs.

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Table 25:Self-reported prevalence of STIs and STIs symptoms

STI

Women

Men

Percentage of women who reported in the past 12 months:

Percentage of men who reported in the past 12 months:

Bad smelling/ abnormal genital discharge

Genital sore/ ulcer

STI, genital discharge, sore, or ulcer

# women who ever had sexual intercourse

STI

Bad smelling/ abnormal genital discharge

Genital sore/ ulcer

STI, genital discharge, sore, or ulcer

# men who ever had sexual intercourse

Age

abnormal

15-24

genital

30.7

32.4

41.0

293

23.4

17.3

15.3

23.4

295

25-39

discharge

30.8

34.7

44.1

426

33.6

23.5

27.8

33.6

473

40-59

31.9

18.8

26.8

31.9

138

28.5

20.8

22.2

28.5

207

Total, 15-59

41.1

28.8

32.7

41.1

857

29.4

21.0

22.8

29.4

975

Married

43.7

28.7

43.7

515

21.3

25.2

31.0

626

Single,

38.8

30.6

31.3

38.8

160

24.6

20.4

16.2

24.6

260

Divorced/ separated

41.9

33.3

31.6

41.9

117

34.3

21.4

25.7

34.3

Widow/ widower

23.4

15.6

18.8

23.4

26.3

21.1

26.3

No education

31.0

22.6

25.2

31.0

155

31.9

24.5

29.8

31.9

Primary

44.1

30.9

36.5

44.1

485

322

23.7

25.3

32.2

537

Secondary +

40.4

27.4

28.9

40.4

208

23.7

15.4

16.3

23.7

338

Apac

23.6

8.2

14.6

23.6

110

15.6

11.3

8.8

15.6

160

Arua

31.1

26.7

20.7

31.1

135

16.9

11.7

10.4

16.9

154

Kasese

32.6

25.4

28.3

32.6

138

27.7

20.5

24.7

27.7

166

Masaka

53.6

39.1

49.7

53.6

151

41.7

31.0

38.1

41.7

168

Rakai

43.8

28.8

36.9

43.8

160

33.5

26.2

24.4

33.5

164

Wakiso

54.0

38.0

38.7

54.0

163

39.9

24.5

28.8

39.9

163

Marital status

Education

District

Treatment of sexually transmitted infections Having untreated STIs increases the risk of acquiring or transmitting HIV. Thus early treatment of STIs can help to forestall HIV risk associated with presence of STIs (Hayes et al., 2010; Ng, Butler, Horvath, & Rutherford, 2011; Ward et al., 2003). Among respondents who reported an STI or a symptom perceived to be an STI in the past 12 months, a high proportion (86% of women and 89% of men) reported that they had sought treatment, from either private or government clinics. Men were more likely

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

to seek treatment from private clinics (45%), while women were more likely to seek treatment from government facilities (51%).

Completing STI treatment Of those that sought treatment, 80 per cent of women and 86 per cent of men reported that they completed their treatment doses. Among men, those that did not complete their treatment doses cited “Did not think STI was any serious health issue to worry about” as the main reason (23%), followed by “pain not being serious” (19%) and “the lack of time to complete dose or ignorance of where to get STI treatment” (13% each). Women cited the failure to get money to complete treatment (27%) and “pain not being serious” (27%) as the major reasons why they could not complete their treatment dose. Other reasons include, “did not think STI was any serious health issue to worry about” (16%), and “lack of time to go for treatment” (10%). Table 26: STI Treatment

Women

Men

Per cent

Number

Per cent

Number

Yes

86.89

305

89.16

255

13.11

10.84

Private facility/clinic

37.67

113

47.35

116

Government facility (hospital/health centre)

53.67

161

43.67

107

Pharmacy/Drug Shop

4.67

6.93

NGO

5.00

2.45

Traditional Healer

3.00

2.86

Others

1.67

1.2

Yes

80.3

241

86.1

217

19.7

13.89

Did you seek treatment

Where did you go to seek treatment

Did you complete dose

4.9.

Access to HIV Counselling and Testing Knowledge of one’s HIV status is an important cornerstone for HIV prevention, treatment and care. During the survey, respondents were asked if they had ever undergone an HIV test and if they had received the results of the test. Overall, 86 per cent of the respondents had ever been tested for HIV. More women reported to have been tested for HIV compared to men (90% and 82% respectively). Among those who had ever been tested for HIV, 76 per cent had been tested within the last 12 months, while about 13 per cent had been tested two or more years earlier. 48

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Over 96 per cent of men and women who had been tested in the last 12 months had received the results of the HIV test. Collectively, these findings suggest a high motivation for people in fishing communities to learn their HIV status. Among those who had been tested for HIV, the majority (63% of women and 56% men) tested at government facilities, while the rest had been tested at NGOs (17% of women and 23% of men) and at private facilities (12% of men and 11% of women). About 9 per cent of men and 8 per cent of women had been tested from other sources, particularly outreach clinics. Table 27: HIV testing history

Women

Men

Per cent

Number

Per cent

Number

Percentage ever tested

90.3

842

81.9

851

Ever tested and received results

97.2

695

97.2

704

% who received results from last HIV test taken in the past 12 months

96.0

626

97.4

649

Ever tested, did not receive results

2.8

Participants were also asked how easy or difficult it was for them to obtain an HIV test. About 88 per cent of the respondent reported that they had found it easy. Those that reported finding it difficult (12%) cited fear of getting an HIV positive status as the main reason why they had found it difficult to obtain a test (87%). Other reasons for the difficulty in obtaining the test included testing centre being far away and hence not easily accessible, long queues at the testing centre, lack of privacy, and HIV test kits not being available. Reasons for non-testing All respondents who had never tested for HIV were asked for the reasons why they have never tested for HIV. About 31 per cent indicated that they did not need to test because they perceived themselves to be at low risk, while 36 per cent reported that they do not want to know if they are infected. Qualitative data reveals that some people prefer to remain ignorant of their HIV status rather than confirm an HIV positive result. Others complained about the long distances to testing facilities. Some people say it is a waste of time they should rather wait and see if they are getting sick then they will just go for the drugs (FGD, women, Apac). Our biggest problem here is that there is no any nearby place that we can go and test from and this makes people donâ&#x20AC;&#x2122;t go for the test and most of them donâ&#x20AC;&#x2122;t know their status. (FGD, men, Masaka)

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

4.10. Susceptibility and Vulnerability of fishing communities to HIV Understanding susceptibility and vulnerability to HIV infection is crucial for identifying effective interventions to control the epidemic. Data from FGD and IDI provide some insights into the factors that increase vulnerability of people in fishing communities to HIV and AIDS. These include availability of daily disposable income, high consumption of alcohol, idleness, a high concentration of social outlets (bar and lodges, discotheques, leisure activities such as gambling and pool tables). Some of these are discussed in turn below:

Daily disposable incomes In contrast to most other occupational groups, fisher-folks get money on a daily basis. Access to daily disposable income was reported to engender risky sexual behaviours, including exchange of money for sex, and excessive alcohol consumption, with fishermen often invoking the slogan, Drink today, for tomorrow we will fish. In fact, there is a perception among some “fisher folks” that money from sale of fish is jinxed and should be spent on luxuries like alcohol and sex rather than saving and investment. Men have money and use it to buy sex and whoever doesn’t offer sex will constantly starve.” (FGD, women, Kasese) Indulgence in alcohol and drugs drives the fishing folks to engage in illicit casual relationships And this is worsened by virtue that condoms are seldom used under the influence of alcohol or drugs.

High Mobility Mobility was also reported to be key driver of HIV in fishing communities. Participants reported that the dynamics of the fishing and fish trade require moving between fishing landing sites, markets and processing factories on almost a daily basis. Fish landing sites are also hubs of trading activity and thus attract other mobile groups such as vendors, casual labourers, traders, transport workers, commercial sex workers, and other women, mostly from neighbouring towns and villages, who migrate to landing sites to run bars, restaurants and offer sexual services. This mobility creates a complex web of sexual mixing and opportunities for multiple sexual partnerships. For example, it is not uncommon for fishermen to have multiple sexual partners at every land site they trade at. Our population here is also a highly mobile one not only the fishermen but even the other people in this business, they move from one landing site to another and this is influenced by market days in different landing sites and this makes them very vulnerable to HIV/AIDS and STD infections because they are always away from home

On the other hand, it is believed that life at the landing sites is anonymous. As a result, it was reported that some people, especially women who have lost their partners due to HIV may consider landing sites as refuge from stigmatization, ending into new sexual relationships.

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

People come from other places, knowing that they have the virus decide to come to the islands and engage into new sexual relationships. They come well dressed and good looking and people follow them up for sex without knowing that the person is infected, (FGD , women, Wakiso).

Transactional sex As referenced earlier, transactional sex is a common practice among fisher folk. Discussions revealed that general lack of income generating opportunities for majority of women in fishing communities drives women to engage in transactional sexual encounters, often with multiple sexual partners. While some marital-like relationships were reported, it was also poignantly observed that for most women in fishing communities, this is rarely about love, mutual trust and friendship. Rather such relationships make sense for as long as they lead to material gains or satisfaction of one’s basic needs. Any man who has money, it is believed can pay for sex from as many women as he wishes. There is no true love nor are there permanent and trustworthy relationships here. Without money, even your wife will leave you for whoever has it. When a fisherman has money, he cannot rest until he has had sex and/ or taken enough beer. At landing sites, sometimes you see a man who comes to buy fish with a lot of money, will offer you some money for sex and some of the women do accept the money in return to satisfy their sexual demand. “…however I think women are more vulnerable to HIV infection because they are the ones who have little access to money and which makes their life miserable and vulnerable. You see most the women who come here are widows or women who have been divorced/ separated, so they do come here to make money so as to enable them take care of their children but because getting money here is not easy they end up in such behaviour since getting money from men is only easy in that way” (IDI, Community leader-women’s affairs, Apac)

The risky nature of the fishing occupation The risky nature of the fishing occupation and the uncertainty surrounding the lives and livelihoods of fisher folks was reported to contribute to fatalistic attitudes and risky behaviours. For example, participants reported that fisher folk are more worried of daily risk of drowning and capsizing than HIV. The argument is that with HIV, you can leave for some years while if a boat capsizes, you die instantly. Consequently, many take sexual risks, abuse alcohol and live each day as it comes without thinking about the future. “Fisher men also believe they will not live longer since they are on the water for the most part of the day or night. This greatly influences both their spending behaviour as well as the sexual behaviour. They say that they can die any time while on the lake fishing and so this pushes them to enjoy life while they are still alive” (IDI, District Fisheries officer, Wakiso district).

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Multiple sexual partners Study participants indicated that the practice of having multiple sexual partners and/or sharing women is highly prevalent in fishing communities. It is believed that no one can ever have a man or woman devoted to him or her alone. As pointed out by a community leader at Bussi (Wakiso district): A woman does not belong to one man. Nobody owns a woman in this community. Whoever wants to have sex with any woman, only needs to approach her and they agree the terms and conditionsâ&#x20AC;&#x2122;.

Similarly, another key informant observed: The men sleep with other women while on other islands and their wives also sleep with other men while the husbands are away. Women are shared here and we are used to it. Even wives know they share the husbands with other women. (Key informant at Kasensero)

Findings also show that since fishing and sex are often nocturnal activities, when the fishing crew are away fishing, their wives are left vulnerable to risky sexual behaviour by other men who prey on them taking advantage of the long working hours of their husbands. The boat owners who are the employers take advantage of the fishermenâ&#x20AC;&#x2DC;s long hours and have illicit sexual relations with the fishermenâ&#x20AC;&#x2DC;s wives and this is not questioned by the fishers for fear that they would lose their jobs.

Idleness/redundancy during day time Idleness and long periods of inactivity during day was also identified as a key driver of HIV in fishing communities. Participants reported that fishing is commonly done at night, and the sale of fish catch is done up to 10.00 am. The long periods of inactivity during day and the urban culture characterising prominent landing sites (e.g. leisure activities such as pool tables, bars) provides an environment conducive for alcohol consumption. In fact, drinking is one of the few recreational activities available in some communities. Both men and women recognised that alcohol consumption led to high risk behaviours.

Poverty Poverty was reported to engender risky sexual behaviours. It is because of poverty, which makes or drives you to do what you will regret. You find a man or woman is sick but has money or rich, so you just decide to love him/her because of poverty. Even these prostitutes it is because of poverty but they would not do it but because they have children and if the husband died or they separated (FGD, men, Masaka). Poverty among women makes them to carry out prostitution. In addition, one will go and get her sister and bring her here and she convinces her that its where also I get my money from (FGD, men, Wakiso).

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

4.11. HIV response in fishing communities 4.11.1.

Availability of HIV Related Services About 77 per cent of the participants reported that they were aware of some HIV and AIDS services provided in their community, by different actors including NGOs, CBO and government health facilities with support from development partners. The most commonly available services reported include HIV counselling and testing (92% of men and 93 of women), condom provision (91% of men and 88% of women), and HIV and AIDS education (72% of men and 75% of women). Other services available include HIV care and treatment (70% of men and 72% of women), PMTCT services (53% of men and 54% of women), STI treatment (55% of men and 59 per cent of women, and social support services (35% of men and 35% of women). During FGDs, most participants reported HIV related services were available, but mostly based in government health facilities, ranging from Health Centre II level to hospitals. Findings however show that most of fishing communities are remote and health facilities are distant, with distances of communities to their nearest health facility ranging from 7km to 35 km. Thus, distance and expenses for transport represent considerable barriers to access and utilisation of some HIV and AIDs specific services. Moreover, when they do eventually reach the nearest health facility, other challenges arise, including shortage of drugs, lack of testing equipment, and inadequate personnel. Collectively, these factors force may people to postpone seeking health care, including sexual and reproductive care services, which increases the risk of late detection of STIs and HIV infection. What makes people not to go to the clinic is because they know that even if I go there after walking long distance I will be given just Panadol. For the rest of the medicine I will be told to buy it for myself. Sometimes there are so many patients, and only one nurse. You are not properly diagnosed because they don’t have the equipment like CD4 [equipment], or HIV testing, they will get the blood, some even take long to bring the results, some results gets mixed up, some even get lost. They will refer me to Masaka Hospital. When you consider the distance and the time I had to waste, it was better to buy Panadol from the shops here (FGD, men, Masaka). The situation right now is many people have AIDs in Kachanga but they don’t have treatment, even blood testing is a problem, people fear it, even the hospitals are very far, and we don’t always have money ready to travel to Masaka. Even those they send this side, they also send us to bigger hospitals (FGD, women, Masaka). “In this area we don’t have any place. Maybe if you go to Entebbe in the hospital, something which is costly in terms of transport” (FGD, Women, Wakiso) “We always have problems in getting ARVS and other AIDS treatment. People from here get the services from ARUA hospital (52 miles)” (IDI, BMU Leader, Arua) “No nearby health facility providing ARVS. The nearby Olujobu health centre III in Rigbo Sub County offers HCT but not ARVS. Olujobu is 4km from Fundo. Health workers from Olujobu come for outreaches like twice a year. They normally do outreach only for child immunization” (IDI, BMU Leader, Arua)

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

For us who have been tested on ARV are getting a lot of problem because we don’t have money to support us, sometimes we go to the health but drugs get finished and that means you have to go to Apac hospital, so when you don’t have money you have to skip taking your drugs for sometimes which is not good. (FGD, women, Apac) Most of the fish landing sites are hard to reach areas. Transport facilities on the water are inadequate. The available services are mainly on the main land yet the majority of the people live on the islands. On the average, people seeking services would need between 2-6 hours of travel before accessing service

Findings also indicate that a number of NGOs are providing HIV and AIDS services in specific communities, ranging from HIV counselling and testing (HCT) and provision of condoms to STI screening and treatment (Table 28). For example, organisations such as the Uganda Fisheries and fish Conservation Association (a national NGO) and Rakai Community Based Health Project (RACHEP) were reported to provide HIV and AIDS service in selected fishing communities In Kasese and Rakai respectively. Some of the HIV and AIDS services provided by these organisations include communitybased education and awareness raising, condom distribution, counselling, testing, and providing ART on outreach basis. …we have partners who have got funding and who are doing various activities in fishing communities. One of them is MARPI which stands for Most at Risk People who deal with commercial sex workers and the e real fishing communities conducting prevention measures and through distributing condoms, sensitizing them and carrying out community dialogues to mention but a few” (IDI, DHO, Wakiso District)

Most of these NGOs rely on community outreaches to deliver specific HIV interventions. These outreach programmes however were perceived by community members to be intermittent, especially for fishing communities located on the Islands and those surrounded by a National Park. We have limited health services for instance RACA [Rakai AIDS Counselling Association] comes once in a while and the hospitals are inaccessible one has to travel to Kyebe (distant neighbouring village) for health services and others from clinics using their own money (IDI, BMU Leader, Rakai District)

In addition, some of these NGOs services extend to only a few fishing communities, leaving many other underserved by HIV and AIDs specific interventions, as reflected in the excerpts below: We even don’t know why NGOs cannot come and help people here and educate people so that people would take issues of their health seriously. Even the nearby health centre like Akokoro does not want to come here and give help to these communities (FGD, women, Apac). The way I see the level at which how people live here in Wansolo, the level of HIV infection is very high because there are no enough services here. There is no health centre to help treat or even educate people here on how to prevent HIV or even how to handle it when you are positive. (FGD, Men, Apac).

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Table 28: Organisations providing HIV and AIDS services in fishing communities

NAME OF NGO

TYPE

DISTRICT

SERVICES PROVIDED

Rakai AIDS Information Network (RAIN)

Local NGO

Rakai

Community mobilisation, condom distribution, HIV counselling and testing,

Rakai Community Based Health Project (RACHEP)

Local NGO

Rakai

Distribution of IEC materials, community based education sessions, HIV counselling and test.

Rakai health science Programme

NGO

Rakai

Male circumcisions, HIV counselling and testing, STI management

RACA

Local NGO

Uganda Cares

NGO

Masaka

HIV counselling and testing, ART

Uganda Fisheries and fish Conservation Association

Local NGO

Kasese

HIV counselling and testing, community based education sessions, condom distribution

Bishop Masereka Foundation

Local NGO

Kasese

Baylor Childrenâ&#x20AC;&#x2122;s Medicine

INGO

Kasese

Northern Uganda Malaria AIDS and Tuberculosis (NUMAT)

Programme NGO funded by USAID

APAC

HCT, Support the health centres and District health department with drugs and technical support/ trainings.

AMREF

NGO

APAC

Safe male circumcision, Radio talk show to the Health department, funding technical support/ training

TASO

National NGO

APAC

Outreaches on VCT, ART clinics

Uganda Reproductive health

NGO

APAC

HIV counselling and testing

Catholic Medical Mission Board (CMMB)

NGO

APAC

Male medical circumcision

Mild May

NGO

Wakiso

HIV counselling and testing, ART/ARVâ&#x20AC;&#x2122;s

TASO

NGO

Wakiso

HIV counselling and testing, condom distribution, ART

HUYS LINK Community initiative

Civil society organization

Wakiso

Community dialogues, sensitization and condom distribution, training and education, mobilization, youth activities

Kyosiga Community Christian Association for Development

Civil Society Organization

Wakiso

Empowering women, ovcs to become self reliant and economically productive though trainings. Giving them soft loans, giving basic necessities like food, scholastic materials

HIV counselling and testing, community based education sessions, condom distribution

MARPI

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

4.12. Location and Population Estimates of fishing communities Table 29: Location and population estimates of fishing communities Name and Location of fishing communities Name of fishing community

Lake

District

Sub-county

Population Estimates Parish

Estimated total population

Gender Male

Female

Source(s) of information

Abei/agee

Apac

Chawente

Atule

350

166

184

BMU/LC register

Agweng

Apac

Nambieso

Ayapi

410

201

209

BMU/LC register

Ajokdong

Apac

Nambieso

Yapi

280

137

143

BMU/LC register

Apalamio

Apac

Akokoro

613

314

299

BMU/LC register

Gweng

Apac

Chawente

Alido

260

124

137

BMU/LC register

Kayei

Apac

Akokoro

Ayeolyec

1680

860

820

BMU/LC register

Kigga

L. Kyoga

Apac

Akokoro

Alaro

846

433

413

BMU/LC register

Wansolo

Apac

Akokoro

Alaro

1094

560

534

BMU/LC register

Wigweng

Apac

Akokoro

Akoko

306

157

149

BMU/LC register

Parabo Landing site

Arua

Pawor Sub county

700

358

342

LC. Chairperson

Fundo Lnading site

Arua

Rigbo sub-county

1220

625

595

LC1 V/Chaiperson

Isirini Landing site

Arua

Ojoko sub-county

960

410

550

LC. Chairperson

Odoi Landing site

Arua

1880

1200

680

LC. Chairperson

Ndiova landing site

Arua

Rhino Camp sub-county

450

270

180

LC. Chairperson

Olari

Kahendero

Lake George

Kasese

Muhokya

Kahendero

3980

1895

2085

District Planning Unit

Kasenyi

Lake George

Kasese

Lake Katwe S/C

Kasenyi

1321

629

692

District Planning Unit

Hamukungu

Lake George

Kasese

Lake Katwe S/C

Hamukungu

3182

1515

1667

District Planning Unit

Katunguru

Kazinga Channel

Kasese

Lake Katwe S/C

Katunguru

2023

963

1060

District Planning Unit

Katwe-Kabatoro

Lake Edward

Kasese

Katwe-Kabatoro Town Council

4643

2211

2432

District Planning Unit

Kayanzi

Lake Edward

Kasese

Nyakiyumbu s/c

1185

564

621

District Planning Unit

Kasensero

L.Victoria

Rakai

Kyebe

15,000

7624

7,376

LC1 Register

Kyabasimba

L.Victoria

Rakai

Kyebe

350

178

172

LC1 Register

Kaserere

Lake Kijjanebalola

Rakai

Kagamba

412

196

216

LC1 Register

Bbaale

Lake Kijjanebalola

Rakai

Kagamba

200

105

LC1 Register

Lwebiriba

Lake Kacheera

Rakai

Kachera

150

Lukunyu

Kagera Fishing area

Rakai

Kyebe

302

154

148

Lambu

L.Victoria

Masaka

Bukakata

Bukibonga

8700

4263

4437

LC1 Register

Kachanga

L.Victoria

Masaka

Bukakata

Bukibonga

600

294

306

BMU Chairman

Namirembe

L.Victoria

Masaka

Kyanamuka

Buyaga

1000

490

510

LC. Chairperson

Dimo

L.Victoria

Masaka

Kyesiga

Bbuliro

2000

980

1020

LC1 Register

Malembo

L.Victoria

Masaka

Kyanamukaaka

Kitunga

LC1 Register

Kigungu

L.Victoria

Wakiso

Division B

Kigungu Ward

1200

618

582

BMU Register

Dewe

L.Victoria

Wakiso

Sissa

Bweya

180

LC1 Register

Makusa

L.Victoria

Wakiso

Division B

Entebbe

450

232

218

BMU Register

Kavenyanja

L.Victoria

Wakiso

Kasanje

Bussi

650

306

344

LC1 Register

Nakabugo

L.Victoria

Wakiso

Makindye-Ssabagabo

Mutungo

188

BMU Register

Kasenyi

L.Victoria

Wakiso

Katabi

Nkumba

1300

665

635

BMU Register

Bugiri

L.Victoria

Wakiso

Katabi

Kisubi

180

Secretary Bmu

Kayanja (Kayanzi)

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

LC1 Register

Bussi/Gulwe

L.Victoria

Wakiso

Kasanje

Bussi

200

106

BMU V/C

Gerenge

L.Victoria

Wakiso

Katabi

Nalugala

600

307

293

BMU Chairman

Koko

L.Victoria

Wakiso

Katabi

Nkumba

200

102

LC1 V/C

Lwamunyu

L.Victoria

Wakiso

Division B

Enteebe

300

154

146

V/C BMU

CONCLUSION AND RECOMMENDATIONS The AIDS epidemic is complex, and successful effort to limit transmission must rely on a combination of biomedical, social and behavioural approaches. This study provides information that will enable programme officials and policymakers to design more effective HIV prevention programmes for people in fishing communities.

Knowledge, Attitudes and Practices of the selected fishing communities on HIV and AIDS and their perceived vulnerability: This study reveals the level of knowledge and its relationship with the attitudes and practices of people in fishing communities. The study finds that knowledge levels regarding HIV and AIDS are higher in some fish landing sites than others. However, knowledge gaps still exist especially misconceptions about HIV which would highlight a need to tailor response efforts to the identified needs in these communities. Similarly, it is important to note that the knowledge about HIV and AIDS prevention does not necessarily translate into changes in behaviour. Recent studies on HIV and AIDS in high risk populations such as fishing communities have revealed a laxity in the adoption of HIV and AIDS risk reduction strategies in these communities and majority of factors are attributed to this. These include; number and type of sex partners, use of condoms, and engagement in transactional sex, among subpopulation living and working in fish landing environments. Findings also revealed that people in fishing communities had a general awareness and knowledge about HIV transmission and prevention. The study revealed a high awareness of these prevention strategies however further analysis indicated discrepancies between knowledge of prevention strategies and actual uptake. The uptake of HIV prevention strategies depended on a number of reasons including the beliefs, practices and lifestyles of fisher folk. Despite knowledge of HIV and AIDS as a â&#x20AC;&#x2DC;killer diseaseâ&#x20AC;&#x2122;, fisher folk were still involved in risky behaviour and they demonstrated knowledge of their potential to get infected with HIV. By their own admission, particularly during focus group discussions, participants mentioned that despite their perceived knowledge of HIV and AIDS and the risks of infection in fishing communities, the attitudes and behaviour of people in fishing communities were not necessarily changing. This finding is consistent with results from similar studies in high risk populations (Farmer, 2006).

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Sexual and behavioural dynamics and risk reduction strategies against HIV and AIDS, STIs and unwanted pregnancies Behavioural patterns and practices of â&#x20AC;&#x2DC;fisher folkâ&#x20AC;&#x2122; and the increased mobility of fishermen accentuate vulnerability and exposure to HIV infection. Vulnerability to HIV and AIDS in fishing communities spans a range of elements related to perception of risk and behaviour. In this study, behavioural dynamics particularly sexual behaviour in fishing communities have been identified as key determinants of high risk levels of fisher folk to HIV infection. Among these are knowledge and awareness, beliefs and practices and adoption of risk reduction strategies. This study also indicates that HIV prevention in the context of fishing communities is perceived to mean the adoption of prevention strategies such as correct and consistent condom use, abstinence, avoidance of multiple sexual partnerships and increased adoption of PMTCT strategies. Majority of respondents indicated that sexual behaviour was directly linked to poor adoption of risk reduction strategies. This was particularly the case for fisher folk who engaged in cross-generational sex, transactional sex and/or sex work and other sexual behaviour that placed them at high risk of HIV infection. Although participants expressed their knowledge of risk reduction strategies like condom use and abstinence, the uptake and correct, consistent use of condoms was reportedly inconsistent. These findings are consistent with results from similar studies which indicate that vulnerability is a major factor influencing sexual behaviour and this is particularly specific for women in fishing communities who are to a large extent economically dependent on men and as a result engage in sex in exchange for money or favours and are at times more likely to remain in relationships they perceive as risky (Allison and Seeley, 2005; McPherson, 2012).

Multiple sexual partnerships: It was noted that one of the indicators of high risk among fisher folk was the practice of engaging in multiple sexual partnerships. A significant number of respondents acknowledged the practice as one that was predominant in fishing communities, cross-cutting, irrespective of gender and age. This, they asserted had a bearing on vulnerability to HIV infection especially with revelations that condom use in such partnerships did not always happen consistently in light of other factors such excessive alcohol use which impacted on the ability of fisher folk to act responsibly while inebriated.

Condom use: The survey findings suggest that participants had used condoms consistently in regular and casual relationships. Married couples were more unlikely to use condoms than those in regular or casual relationships. However, participants in the qualitative study indicated that, condom use in general was low and they mentioned factors like alcohol and ability to negotiate for safer sex as hindering consistent condom use. Participants felt that alcohol often played a significant role in impairing oneâ&#x20AC;&#x2122;s judgement to practice safe sex; similarly, negotiating safe sex with partners (married or transactional) was difficult. A reason given for married couples was the idea that sex in marriage is necessary for family expansion. In transactional relationships, it was stated in focus group discussions that men often shunned the use of condoms especially when they were paying for sex.

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

Transactional sex: Recent studies on fishing communities in Sub-Saharan Africa have highlighted that the occurrence of transactional sexual relationships is apparent. This study reveals that women enter into transactional sexual relationships for both monetary and material gain. In all study sites, it was noted that the presence of commercial sex workers is high and this is e land site to another. Findings from this study suggest that there are a number of mobile sex workers who come to the landing sites when the fish catches are fishermen come from different parts of the country, leaving their homes in search for a livelihood and as such are at risk of HIV infection. Similarly, the presence of fishermen creates an influx of commercial sex workers who also migrate from one landing site to another seeking work. Although survey results reveal that it was more likely for casual sex partners to adopt safe sex practices, it is still important to note that safe sex was influenced by other factors and this often had an overriding effect on choice of safe sex. This was especially the case where sexual partners were inebriated prior to sexual intercourse. The findings suggest a need for aggressive HIV and AIDS prevention and response in the fishing communities. The availability of HIV and AIDS services, although visible, are inadequate to meet the demand. Similarly, access to services like ART centres which are often miles away impedes effective adherence for patients who have to travel long distances to centres. Inconsistent HIV outreach services in most remote fishing communities presents a significant barrier to effective HIV and AIDS prevention especially for sensitization, voluntary counselling and testing. Findings from this study suggest a laxity in behaviour change communication, a mechanism that could effectively dispel myths and misconceptions about HIV and AIDS that still exist in fishing communities.

Recommendations There is a pressing need of HIV and AIDS services in fishing communities. Majority of the fishing communities in remote parts of the country (particularly, Apac, Arua, Kasese, Rakai and Masaka) have gaps in HIV service provision. Despite the presence of support from government hospitals under their HIV and AIDS programmes, resources are limited. â&#x20AC;˘

There is need for increased health education with emphasis on the aetiology of the disease particularly targeting the youth and women who appear to have poorer knowledge or access to services where they may interface with educational sessions. Patientsâ&#x20AC;&#x2122; understanding of the cause and outcome of disease affects their health seeking behaviour. High knowledge of HIV and AIDS has been associated with access, retention and adherence to care (Winchester et al., 2013; McGrath et al., 2012; Boateng et al. 2013). Therefore, given the low levels of knowledge exhibited in fishing communities, a critical starting point is education and communication interventions to improve knowledge levels among fisher folk.

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

â&#x20AC;˘ Findings indicate that patients have to travel long distances from their villages to the hospitals and ART centres to access services (with distances of communities to their nearest health facility ranging from 7km to 35 km). Thus a need to improve access to HIV services through reducing distance, travel times or number of clinic visits is urgently required. HIV services should be further decentralized to the lowest level health centres. In Uganda, the health system provides for a health facility at the lowest level to be within 5 KM of reach. These services, while improving in many areas in Uganda, need to be promoted for HIV care in fishing villages. For instance, availability of HIV testing and counselling services need to be increased within fishing villages by providing them at HC I level. Additionally, outreach services should be implemented with a view to reduce the travel distances or number of times that people seeking HIV care have to undertake. â&#x20AC;˘ To increase availability of resources needed for better HIV and AIDS care service delivery, partnerships among key service providers of HIV and AIDS services in fishing communities need to be strengthened. One of the significant findings from the study was that there was duplication of services as various organisations that provided HIV and AIDS did not work together. All Interviews held at district level recommended that it was important to strengthen partnerships through networking, joint planning and implementation of HIV and AIDS services. Further study of potential partnerships among service providers currently working in similar hard-to reach areas would also be needed to inform policy. â&#x20AC;˘ Targeted Behaviour Change Communication interventions should be implemented to further improve the level of knowledge and perceptions about HIV and AIDS. In these fishing villages, although knowledge levels about the mode of transmission were high, some participants perceived HIV to be spread by witchcraft or mosquitoes. Additionally, while prevention knowledge was also high, a large proportion of participants had poor perceptions about condom use, multiple sexual partnerships and other high risk behaviors. This may indicate that, in spite of educational interventions currently implemented, they are not demystifying poor perceptions. Thus it is pertinent to tailor the educational interventions through targeted behavioural change communication. Such change communication should focus on the unique high risk behavioural characteristics of fishing communities. The sociocultural context of fishing communities should inform national level communication strategies and intervention programming. Correct communication and messages on HIV transmission modes, prevention strategies and treatment options should be disseminated in a clear and consistent manner. Further study into how to develop clear and consistent messages tailored to the socio-cultural context in fishing communities is needed.

HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

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HIV Knowledge, Attitudes and Practices and Population Size Estimates of Fisherfolk in Six Districts in Uganda November 2013

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