Cango Lyec (Healing the Elephant): HIV incidence in post-conflict Northern Uganda

Achilles Katamba; Martin D Ogwang; David S Zamar; Herbert Muyinda; Alex Oneka; Stella Atim; Kate Jongbloed; Samuel S Malamba; Tonny Odongping; Anton J Friedman; Patricia M Spittal; Nelson K Sewankambo; Martin T Schechter

doi:10.1016/j.eclinm.2020.100408

Cango Lyec (Healing the Elephant): HIV incidence in post-conflict Northern Uganda

EClinicalMedicine. 2020 Jun 18:23:100408. doi: 10.1016/j.eclinm.2020.100408. eCollection 2020 Jun.

Authors

Affiliations

¹ Makerere University College of Health Sciences, School of Medicine, Uganda.
² St Mary's Hospital - Lacor, Northern Uganda Program on Health Sciences.
³ University of British Columbia, School of Population & Public Health, Canada.
⁴ Makerere University, Child Health Development Center, Uganda.
⁵ Cango Lyec Project, Makerere University, Child Health Development Center, Uganda.
⁶ Uganda Virus Research Institute (UVRI) - HIV Reference Laboratory Program, Uganda.
⁷ BC Children's Hospital Research Institute, Canada.

Abstract

Background: Civil war in Northern Uganda resulted in widespread atrocities, human rights violations, and death, and caused millions to flee to internally displaced persons camps. War-related traumas combined with difficulties accessing HIV prevention and health services has led to extreme HIV-related vulnerability among conflict-affected people who survived the war. Objectives were to (1) determine HIV incidence among conflict-affected people in Northern Uganda and (2) identify vulnerabilities associated with HIV infection.

Methods: The Cango Lyec (Healing the Elephant) Project is a prospective cohort involving conflict-affected populations in three districts in Northern Uganda. In 2011, eight randomly selected communities were mapped, and a census was conducted. Consenting participants aged 13-49 years were followed over three rounds of follow-up. Longitudinal data collected included war-related experiences, sexual vulnerabilities, and sociodemographics. Blood samples were tested for HIV-1 at baseline and each 12-month follow-up. Multivariable Cox proportional hazard models determined factors associated with HIV incidence.

Findings: Overall, 1920 baseline HIV-negative participants with at least one follow-up contributed 3877 person-years (py) for analysis. Thirty-nine (23 female, 16 male) participants contracted HIV during follow-up. Age- and gender-standardised HIV incidence rate was 10•2 per 1000py (95%CI: 7•2-14•0). Stratified by sex, the age-adjusted HIV incidence was 11•0 per 1000py (95%CI: 6•9-16•6) among women and 9•4 per 1000py (95%CI: 5•3-15•3) among men. Adjusting for confounders, factors associated with risk of HIV included: having been abducted (HR: 3•70; 95%CI: 1•87-7•34), experiencing ≥12 war-related traumatic events (HR: 2•91 95%CI: 1•28-6•60), suicide ideation (HR: 2•83; 95%CI: 1•00-8•03), having ≥2 sexual partners (HR: 4•68; 95%CI: 1•36-16•05), inconsistent condom use (HR: 6•75; 95%CI: 2•49-18•29), and self-reported genital ulcers (HR: 4•39; 95%CI: 2•04-9•45).

Interpretation: Conflict-affected participants who had experienced abduction and multiple traumas during the war were at greater risk of HIV infection. Trauma-informed HIV prevention and treatment services, and culturally-safe mental health initiatives, are urgent for Northern Uganda.

Keywords: Conflict-affected people; HIV incidence; HIV/AIDS; Mental health; Northern Uganda; Trauma.