At the end of 2013, the Government of Uganda issued guidance recommending provision of AntiRetroviral Treatment (ART) to HIV-positive people in key populations, including female sex workers, regardless of CD4 cell count. We describe the implementation of this new guidance in a clinic serving women at high risk of HIV infection in Kampala. Between July and December 2015, we conducted repeat in-depth interviews with 15 women attending the clinic after the change in guidelines, to explore their perceptions regarding prompt ART initiation. The sample included some women who were HIV-negative and women who had both started and deferred ART. We conducted a data-led thematic analysis of the material from the interviews. A total of 257 of 445 eligible women had started ART; others were undecided or had not returned to the clinic after receiving the new information. Participants recounted varying experiences with the provision of prompt treatment. At an individual level, a history of treatment for opportunistic infections and other illnesses, coupled with relatively poor health, encouraged some to initiate ART promptly. However, knowledge of friends/relatives already on ART who had experienced side effects caused others to delay starting, fearing the same experience for themselves. A number of women questioned why they should start treatment when they were not sick. Situational factors such as work and residence (with many sharing single rooms) caused discomfort among newly diagnosed women who feared disclosure and stigma that would result from taking ART when they were not ill. Alcohol consumption and irregular working hours affected perceptions of future adherence, making prompt ART harder to embrace for some. Our findings show the challenges that influence the delay of treatment initiation, and/or the decision to defer receiving information on ART, with implications for the success of the test and treat programmes and guidelines.ARTICLE HISTORY

With a focus on Uganda, this paper examines men's condom use in sexual relationships with casual partners and what this might tell us about men's vulnerability to HIV-infection. We carried out repeat interviews with 31 men attending a clinic serving women at high risk for HIV infection and their partners in Kampala. We found that the experience of condom-less sex in the men's youth, itself the outcome of a restrictive home environment, was perceived as influencing later unsafe sexual behaviour. Peer pressure encouraged men to have multiple partners. Alcohol negatively affected condom use. Men often opted not to use a condom with women they thought looked healthy, particularly if they had had sex with the same woman before. Some men who were HIV-positive said they saw little point in using condoms since they were already infected. A concerted effort is required to reach men, like those in our study, to halt HIV and the transmission of other sexually transmitted infections.

ObjectivesWe assessed the prevalence and risk factors associated with virological failure among female sex workers living with HIV on antiretroviral therapy (ART) in Kampala, Uganda.MethodsWe conducted a cross-sectional study between January 2015 and December 2016 using routinely collected data at a research clinic providing services to women at high risk of STIs including HIV. Plasma samples were tested for viral load from HIV-seropositive women aged ≥18 years who had been on ART for at least 6 months and had received adherence counselling. Samples from women with virological failure (≥1000 copies/mL) were tested for HIV drug resistance by population-based sequencing. We used logistic regression to identify factors associated with virological failure.ResultsOf 584 women, 432 (74%) with a mean age of 32 (SD 6.5) were assessed, and 38 (9%) were found to have virological failure. HIV resistance testing was available for 78% (28/38), of whom 82.1% (23/28) had at least one major drug resistance mutation (DRM), most frequently M184V (70%, 16/23) and K103N (65%, 15/23). In multivariable analysis, virological failure was associated with participant age 18–24 (adjusted OR (aOR)=5.3, 95% CI 1.6 to 17.9), self-reported ART non-adherence (aOR=2.6, 95% CI 1.2 to 5.8) and baseline CD4+ T-cell count ≤350 cells/mm3 (aOR=3.1, 95% CI 1.4 to 7.0).ConclusionsA relatively low prevalence of virological failure but high rate of DRM was found in this population at high risk of transmission. Younger age, self-reported ART non-adherence and low CD4+ T-cell count on ART initiation were associated with increased risk of virological failure.

ObjectivesWe aimed to assess mobility patterns and reasons for high mobility among young women engaged in sex work within a randomised controlled trial to gauge how mobility may hinder access to health services and enhance HIV risk in a highly vulnerable population.SettingParticipants were recruited from a clinic in Kampala, Uganda set up for women at high risk of HIV infection.ParticipantsAdolescent girls and young women engaged in sex for money and/or commodities are at particular risk in countries with high HIV prevalence and high fertility rates. High mobility increases exposure to HIV risk. Women participants were eligible for the parent study if aged 15–24 years, HIV negative and engaged in sex work. For this substudy, 34 qualitative interviews were held with 14 sex workers (6 HIV positive, 8 HIV negative), 6 health worker/policy makers, 3 peer educators, 5 ‘queen mothers’ and 6 male partnersMeasuresParticipants used Google Maps to identify work venues at 12-month and 18-month study visits. We also conducted 34 interviews on mobility with: high-risk women, male partners, health workers and sex-worker managers. Topics included: distance, frequency and reasons for mobility. We used Python software to analyse mapping data.ResultsInterviews found in depth narratives describing lack of education and employment opportunities, violence, lack of agency, social, sexual and familial support networks and poverty as a complex web of reasons for high mobility among young sex workers.ConclusionsYoung women at high risk are highly mobile. Reasons for mobility impact access and retention to health services and research activities. Strategies to improve retention in care should be cognisant and tailored to suit mobility patterns.Trial registration numberNCT03203200.

Data on implementation of ‘Test and Treat’ among key populations in sub-Saharan Africa are still limited. We examined factors associated with prompt antiretroviral therapy/ART (within 1 month of HIV-positive diagnosis or 1 week if pregnant) among 343 women at high risk for HIV infection in Kampala-Uganda, of whom 28% initiated prompt ART. Most (95%) reported paid sex within 3 months prior to enrolment. Multivariable logistic regression was used to determine baseline characteristics associated with prompt ART. Sex work as main job, younger age and being widowed/separated were associated with lower odds of prompt ART; being enrolled after 12 months of implementing the intervention was associated with higher odds of prompt ART. Younger women, widowed/separated and those reporting sex work as their main job need targeted interventions to start ART promptly after testing. Staff supervision and mentoring may need strengthening during the first year of implementing ‘test and treat’ interventions.