Nambusi Kyegombe

Background: Climate change is increasingly recognised as a major threat to health in Uganda, yet gaps in implementation, financing and coordination may limit the country’s climate–health response. This study aimed to understand how national-level interest-holders perceive the availability, adequacy and functioning of policy, governance and financing mechanisms for integrating health into climate action. Methods: In-depth interviews were conducted with nine key interest-holders purposively selected from ministries, departments and agencies responsible for health, climate change, planning and finance and from academic institutions engaged in climate and health programming and research. A total of 14 individuals were approached and 9 agreed to participate. Interviews were audio-recorded, transcribed verbatim and analysed thematically. Saturation was assessed iteratively by monitoring whether successive interviews yielded new codes or substantively new themes. Results: Interest-holders described a relatively strong climate policy and legal framework that increasingly recognises health but does not fully operationalise climate–health action. Implementation was reported to be constrained by underfunding, fragmented and siloed governance and weak subnational capacity. Climate-related hazards were reported to be damaging health facilities, disrupting access to care and increasing climate-sensitive disease burdens, while local innovations and emerging climate-smart practices remain too limited to guide implementation at scale. Major gaps in evidence for effective health-focused adaptation and mitigation and in climate–health training and public education were identified as limiting the ability of decision-makers, health workers and communities to anticipate and respond to climate risks. Conclusions: Uganda’s relatively robust climate policy framework is undermined by incomplete implementation, driven by constrained financing, limited evaluation and fragmented delivery systems. Strengthening climate-resilient health systems will require embedding climate–health policies into routine health planning and financing, empowering local action using climate information and investing in research, training and public education. Cross-sectoral actions grounded in whole-government and multisectoral governance approaches are also essential to address climate–health challenges.

Despite recognition that decolonisation is important, there remains a lack of conceptual clarity on what exactly decolonising might involve. Our qualitative study explores how colonialism and decolonisation are conceptualised within the field of violence against women and girls (VAWG), and identifies practical strategies to decolonise funding, programming and research. Our findings draw from 17 semi-structured interviews, eight focus group discussions (FGDs) and five feedback workshops (n = 83) with practitioners, researchers and donors supporting VAWG prevention and response. We identified participants through existing professional networks and used snowball sampling to recruit participants from all world regions. Interviews and FGDs were conducted in English, French, Portuguese and Spanish. We used a reflexive thematic approach for analysis. There was confusion and disagreement about what the term ‘decolonisation’ means. To address this, VAWG actors must identify the legacy and impact of colonialism for the field, and clarify the roles of Northern and Southern actors in decolonising. Our findings highlight that the area where most work is still needed is around VAWG programming, where coloniality may be embedded into programme design and implementation, requiring more concerted actions to decolonise. Funding was also identified as a key area where structural reform is needed. Research, however, was an area where there appeared to be much higher awareness and action related to decolonising, linked to momentum around dismantling research-based power hierarchies outside of the VAWG field. This research contributes to articulating the main barriers to decolonising and identifies practical actions for funding, programming and research within the VAWG field and beyond.

Pre-exposure prophylaxis (PrEP) is highly effective at reducing HIV acquisition. We aimed to estimate usage of oral-PrEP, and factors associated with adherence among female sex workers (FSWs) in Nairobi, Kenya, using a novel point-of-care urine tenofovir lateral flow assay (LFA). The Maisha Fiti study randomly selected FSWs from Sex Worker Outreach Program clinics in Nairobi. Data were collected from 1003 FSWs from June-October 2019, including surveys on self-reported oral-PrEP adherence. Adherence was also measured using the LFA for HIV-negative FSWs currently taking oral-PrEP. Informed by a social-ecological theoretical framework, we used hierarchical multivariable logistic regression models to estimate associations between individual, interpersonal/community, and structural/institutional-level factors and either self-reported or LFA-assessed adherence. Overall, 746 HIV-negative FSWs aged 18–40 participated in the study, of whom 180 (24.1%) self-reported currently taking oral-PrEP. Of these, 56 (31.1%) were adherent to oral-PrEP as measured by LFA. In the multivariable analyses, associations with currently taking oral-PrEP included having completed secondary education, high alcohol/substance use, feeling empowered to use PrEP, current intimate partner, no recent intimate partner violence, having support from sex worker organisations, experiencing sex work-related stigma, and seeking healthcare services despite stigma. Associations with oral-PrEP LFA-measured adherence measured included having only primary education, experience of childhood emotional violence, belonging to a higher wealth tertile, and being nulliparous. Oral-PrEP adherence, measured by self-report or objectively, is low among FSWs in Nairobi. Programs to improve oral-PrEP usage among FSWs should work to mitigate social and structural barriers and involve collaboration between FSWs, healthcare providers and policymakers.

Objective To explore factors associated with early age at entry into sex work, among a cohort of female sex workers (FSWs) in Nairobi, Kenya. Background Younger age at sex work initiation increases the risk of HIV acquisition, condom non-use, violence victimisation and alcohol and/or substance use problems. This study aimed to understand factors in childhood and adolescence that shape the vulnerability to underage sex work initiation. Design Building on previous qualitative research with this cohort, analysis of behavioural–biological cross-sectional data using hierarchical logistic regression. Participants and measures FSWs aged 18–45 years were randomly selected from seven Sex Workers Outreach Programme clinics in Nairobi, and between June and December 2019, completed a baseline behavioural–biological survey. Measurement tools included WHO Adverse Childhood Experiences, Alcohol, Smoking and Substance Involvement Screening Test and questionnaires on sociodemographic information, sexual risk behaviours and gender-based violence. Descriptive statistics and logistic regression were conducted using hierarchical modelling. Results Of the 1003 FSWs who participated in the baseline survey (response rate 96%), 176 (17.5%) initiated sex work while underage (Conclusions Lower education level and childhood homelessness, combined with sexual violence and sexual risk behaviours in childhood, create pathways to underage initiation into sex work. Interventions designed for girls and young women at these pivotal points in their lives could help prevent underage sex work initiation and their associated health, social and economic consequences.

Introduction: Little is known regarding the attitudes and perspectives of young people and healthcare workers in Botswana about dual self-testing for HIV and STIs including its acceptability, or their perceptions of the opportunities and limitations of this approach. Methods: From July to November 2021, 25 young people and 6 healthcare workers were purposively sampled for in-depth telephone interviews conducted in English or Setswana. The interviews followed a semi-structured topic guide, were audio recorded, transcribed, and analysed thematically using deviant case and constant comparative techniques. The study was part of a pilot project evaluating dual self-testing for HIV and STIs among young people in Gaborone. Results: We found that most of the young people were already aware of their HIV status and were motivated to participate in self-testing mainly because they were interested in learning their STI status. Whilst most were excited about the autonomy and convenience offered by self-testing, some participants expressed nervousness particularly of the finger-prick process, and preferred healthcare worker-administered tests. Both young people and healthcare workers raised concerns about the potential negative mental health outcomes of unexpected test results and emphasized the importance of pre- and post-test counselling and seamless linkage to care. Conclusion: Dual self-testing for HIV and STIs has the potential to empower young people to take control of their sexual health. However, it is crucial to ensure that proper support and counselling services are in place, along with effective mechanisms for linkage to care. This study emphasizes the importance of integrating pre- and post-test counselling into self-testing programs to ensure that young people feel adequately supported throughout the testing process. By doing so, self-testing can become a valuable tool for improving the sexual health outcomes of young people in Botswana.

Objective To explore the structural and social co-factors that shape the early lives of women who enter sex work in Nairobi, Kenya. Design Thematic analysis of qualitative data collected as part of the Maisha Fiti study among female sex workers (FSWs) in Nairobi. Participants and measures FSWs aged 18–45 years were randomly selected from seven Sex Workers Outreach Programme clinics in Nairobi and participated in baseline behavioural–biological surveys. Participants in this qualitative study were randomly selected from the Maisha Fiti study cohort and were interviewed between October 2019 and July 2020. Women described their lives from childhood, covering topics including sex work, violence and financial management. Results 48 out of 1003 Maisha Fiti participants participated in the in-depth qualitative interviews. FSWs described how physical and sexual violence, poverty and incomplete education in their childhood and adolescence intertwined with early pregnancy, marriage, intimate partner violence and relationship breakdown in their adolescence and early adulthood. The data analysis found clear syndemic relationships between these risk factors, particularly childhood violence, poverty and incomplete education and highlighted pathways leading to financial desperation and caring for dependents, and subsequent entry into sex work. Women perceived sex work as risky and most would prefer alternative work if possible, but it provided them with some financial independence and agency. Conclusions This is the first study in Kenya to qualitatively explore the early lives of sex workers from a syndemic perspective. This method identified the pivotal points of (1) leaving school early due to poverty or pregnancy, (2) breakdown of early intimate relationships and (3) women caring for dependents on their own. Complex, multi-component structural interventions before these points could help increase school retention, reduce teenage pregnancy, tackle violence, support young mothers and reduce entry into sex work and the risk that it entails by expanding livelihood options.

Young people, particularly adolescent girls and young women, represent a growing proportion of those living with HIV. Edutainment programmes have been widely used throughout the world to “educate” and “entertain” audiences and tackle serious social issues in bold and engaging ways. This paper examines the extent to which an edutainment programme, MTV-Shuga, was reported to influence young people’s engagement with sexual and reproductive health (SRH) information in rural KwaZulu-Natal, South Africa. In 2019 we conducted eight community-based screenings of MTV-Shuga episodes followed by 25 individual in-depth interviews and 13 focus group discussions with young people aged between 15 and 30. Interviews were audio recorded and transcribed verbatim. Data analysis was thematic and complemented by constant comparison and deviant case analysis techniques. In this rural and poor setting with a high burden of HIV, young people exhibited high levels of awareness of SRH and HIV but had constrained access to services, and limited ability to engage with parents or guardians on SRH matters. MTV Shuga provided an entertaining guide of ways to navigate the risks that they faced in a way that resonated with them. The findings highlight the importance of enabling young people in rural areas to watch MTV Shuga with peers in a safe space in which discussion of the content is facilitated. There is also value in encouraging parents to watch MTV Shuga as a means of enabling discussions between children and adults in their lives about SRH matters.

Introduction: Ugandan adolescent girls and young women are disproportionately impacted by human immunodeficiency virus, and this is largely driven by their engagement in transactional sex. Globally, parent–daughter communication about sex is associated with increased contraceptive use and delayed/decreased sexual activity, but research on parent–daughter communication about transactional sex is lacking. This paper elucidates local perspectives on, and experiences of parent–daughter communication about sex and transactional sex, to inform family‐level comprehensive sexuality education interventions.Methods: We conducted a secondary, thematic analysis of 13 focus group discussions (n = 119) and 30 in‐depth interviews collected between 2014 and 2015 with adolescent girls and young women aged 14+, and men and women in Kampala and Masaka.Results: We found that parents used three approaches to discuss sex and transactional sex with their daughters: (1) frightening their daughters into avoiding sex; (2) being “strict”; and (3) relying on mothers rather than fathers to “counsel” daughters. Mother–daughter communication about transactional sex was common, but frequently unidirectional. Adolescent girls and young women bringing home gifts sparked conversations about the risks of transactional sex, although less in poorer households. Mothers felt they lacked control over their daughters' sexual behaviors and thus restricted their movements and friendships to try to prevent them from having sex. In contrast to previous research, we found some evidence of mothers encouraging condom use and father–daughter communication about sex.Conclusions: Family‐level comprehensive sexuality education interventions targeting parent–daughter communication about sex could further highlight the role that fathers might play, and emphasize communication about the inequitable power dynamics in transactional sex and condom negotiation skills, while reducing fear surrounding parent–daughter communication.