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Abstract

This thesis is based on research on the epidemiology and prevention of HIV among adults in rural Masaka district, Uganda (1989-2010). Arising from this research are 10 published papers, which I have used to explore three research questions: (i) what are the trends in HIV prevalence and incidence in rural Uganda? (ii) what are the key determinants of these trends? (iii) what new strategies could be used to prevent HIV infection in this population? The studies involved four adult cohorts: a general population cohort to monitor HIV prevalence and incidence trends through annual household and serological surveys; an STD/behavioural intervention cohort; a cohort for HIV vaccine preparedness studies; and a cohort of HIV-negative women in discordant couple relationships to evaluate HIV biomedical interventions. The findings from the published papers are summarised. Additional analyses were conducted to include prevalence and incidence data up to 2008. The time trends were examined using a proximate-determinants framework. A comparison of the observed trends was also made with other available national data as well as data from two other African countries. There was a significant decline in HIV prevalence for all ages in the 1990s followed by an increase in the 2000s. Similarly, HIV incidence declined significantly in the 1990s in all adults although there were no clear trends in the 2000s. A net outflow of HIV positive migrants, mortality among HIV positive individuals and a decrease in risky sexual behaviour in the 1990s seem to have been important factors in explaining the decline. The increase in prevalence in the 2000s is explained partly by improved survival due to ART and possibly complacency leading to increased risky sexual behaviour.Two HIV intervention trials (of STDlbehaviour change and a phase 3 vaginal microbicide) are also discussed. Neither trial showed any effect on HIV transmission. To explain the findings from these trials, a conceptual framework for discussing negative results from HIV prevention trials has been used. The possible explanation for the negative results was that the concepts were right but the actual interventions were "inert" or insufficient to demonstrate impact. There was also evidence that there were deficiencies in the design and delivery of the school-based component of the behavioural intervention. In recognition that the epidemic continues unabated, I have addressed priorities for future HIV prevention research on biomedical and behavioural interventions. The cohorts established and research capacity built will continue to provide new opportunities for monitoring and preventing the transmission of HIV in this population.

Publication Type:	Thesis (Doctoral)
Subjects:	R Medicine > RA Public aspects of medicine
Departments:	School of Health & Psychological Sciences Doctoral Theses School of Health & Psychological Sciences > School of Health & Psychological Sciences Doctoral Theses

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