Simon Mwima

Background: Adolescents and young adults (AYAs) from key and priority populations face persistent challenges with sustained engagement in HIV pre-exposure prophylaxis (PrEP) care. While PrEP initiation has expanded across sub-Saharan Africa, evidence on long-term retention and determinants of disengagement among AYAs remains limited. We examined time to PrEP disengagement and associated factors among AYAs initiating PrEP in eastern Uganda. Methods: We conducted a retrospective longitudinal analysis of routinely collected program data for AYAs aged 15–29 years from key and priority populations who initiated PrEP between 2019 and 2025 at Mbale Regional Referral Hospital. Time to PrEP disengagement was assessed using Kaplan– Meier survival analysis and Cox proportional hazards regression. Multivariable models adjusted for sociodemographic, relational, behavioral, and service delivery factors. Sensitivity analyses redefined the time origin to day 91 following PrEP initiation to reflect the programmatic 90-day grace period. Results: Among 3,553 AYAs initiating PrEP, the median time to disengagement was 284 days (95% CI: 273–295). The median age was 24 years (interquartile range [IQR]: 20–26). The probability of remaining engaged in PrEP care declined from 60.1% at 90 days to 20.2% at 365 days. Survival patterns differed significantly by population category and sex at birth but not by age group. In adjusted analyses (N = 3,391), knowledge of a partner’s HIV status (aHR = 2.04; 95% CI: 1.82– 2.29) and initiation through community-based services (aHR = 1.42; 95% CI: 1.17–1.72) were associated with faster disengagement. Married participants had lower hazards of disengagement compared with single participants (aHR = 0.69; 95% CI: 0.64–0.76). Reporting an STI syndrome (aHR = 0.42; 95% CI: 0.32–0.55) or recent gender-based violence (aHR = 0.76; 95% CI: 0.60– 0.96) was associated with reduced disengagement. Findings were highly consistent in sensitivity analyses using an alternative risk-period definition. Conclusions: PrEP disengagement among AYAs occurs rapidly following initiation, with substantial attrition within the first year. Relational factors, service delivery modality, and population-specific vulnerabilities strongly shape retention trajectories. These findings underscore the need for risk-responsive, differentiated PrEP delivery strategies that strengthen partner-based services, integrate STI and GBV screening, and adapt retention support for AYAs in community and facility settings.

Introduction: The disclosure of oral pre-exposure prophylaxis (PrEP) use among adolescent girls engaged in transactional sex in Uganda is a complex process shaped by stigma, fear of judgment, misconceptions, and the threat of violence. This qualitative study explores the strategies these adolescents use to navigate these challenges, drawing on resilience theory and asset-based approaches.Methods: Between April 2018 and May 2019, cross-sectional semi-structured interviews were conducted with Ugandan adolescent girls aged 18–24 engaged in transactional sex to explore their experiences of PrEP disclosure. Data were analyzed using a thematic network analysis approach, focusing on how participants managed the social and psychological barriers to disclosure.Results: The study found that stigma, misconceptions about PrEP, and fear of judgment or violence from clients and families were significant barriers to disclosure. However, adolescent girls employed multiple strategies to navigate these challenges. These included relying on peer support, selective disclosure to trusted individuals, and drawing on personal strength and resilience. Support from healthcare providers and access to youth-friendly health services further helped participants manage the risks associated with PrEP disclosure. Many participants used a combination of these strategies, adapting their approach to different social contexts.Conclusion: This study highlights the complex strategies adolescent girls engaged in transactional sex in Uganda use to disclose PrEP use amidst significant barriers. The findings emphasize the need for targeted interventions that focus on strengthening peer support, enhancing the role of healthcare providers, and creating safe spaces for disclosure. By integrating these strategies into PrEP delivery models, public health efforts can empower these vulnerable populations to disclose and adhere to PrEP more confidently, improving HIV prevention outcomes.

Introduction: In Uganda, fisherfolk have an HIV prevalence between 15% and 40%, significantly higher than the national average of 5.5%. Pre-exposure prophylaxis (PrEP) is effective in preventing HIV but faces challenges in uptake and continuation among fisherfolk. This study explores factors influencing PrEP continuation and discontinuation among fisherfolk in Uganda using the Consolidated Framework for Implementation Research (CFIR). Methods: Participants were recruited from two fishing communities near Entebbe, Uganda. One community received enhanced PrEP support (adherence support, educational workshops and check-in calls), while the other received standard healthcare outreach. Forty fisherfolk (20 who continued PrEP and 20 who discontinued PrEP) were interviewed 6 months after initiating PrEP. Data were analysed using directed content analysis, with high inter-rater consistency. Ethical approval and informed consent were obtained. Results: Findings highlighted several determinants of PrEP continuation and discontinuation across the CFIR domains. Intervention characteristics such as side effects and the pill burden were significant barriers, particularly for women who reported nausea and stomach issues. Individual characteristics revealed that perceived HIV risk influenced PrEP use, with women’s decisions often influenced by their partners' behaviours and mobility. However, insufficient information and education, especially among women, led to misunderstandings and discontinuation. Inner-setting factors like mobility issues and the distance to healthcare clinics posed significant barriers exacerbated by the geographical isolation of fishing communities. In the outer setting, high HIV prevalence motivated PrEP initiation, but stigma, particularly the misconception that PrEP is an antiretroviral drug used by people living with HIV, led to discontinuation. Conclusion: Fisherfolk in Uganda encounter multiple barriers to PrEP continuation, with women facing more significant challenges. Enhanced support strategies are essential for improving PrEP adherence and informing future HIV prevention interventions in high-risk populations.

Stigma and discrimination negatively impact the prevention, treatment, and care of HIV. The COVID-19 pandemic increased this complexity and created a cluster of synergistic health contexts, wherein the physiological aspects of HIV and the social and environmental conditions increased the vulnerability in health outcomes for youth living with HIV (YPLHIV) in Kampala, Uganda. We used interpretive phenomenological analysis (IPA) and the syndemics framework to understand the lived experiences of YPLHIV. From December 2020 to May 2021, six qualitative focus groups were held with 31 youth living with HIV to understand the lived experiences of YPLHIV. The guided questions used were audio-recorded, transcribed verbatim, and coded for thematic analysis. Findings highlight the complexity of intersecting stigma of HIV and COVID-19 that have worsened antiretroviral treatment adherence and mental health issues due to lack of access to critical needs such as fears of food insecurity, health-related worries, the fear of perishing due to COVID-19, and human rights concerns related to gender and sexual identity. The study recommends addressing human rights–related concerns in addition to health-related concerns to comprehensively mitigate the syndemics of HIV and COVID-19 for YPLHIV in Uganda.

There is a dearth of evidence-based post-rape clinical care interventions tailored for refugee adolescents and youth in low-income humanitarian settings. Comics, a low-cost, low-literacy and youth-friendly method, integrate visual images with text to spark emotion and share health-promoting information. We evaluated a participatory comic intervention to increase post-exposure prophylaxis (PEP) knowledge and acceptance, and prevent sexual and gender-based violence, in Bidi Bidi refugee settlement, Uganda. Following a formative qualitative phase, we conducted a pre-test post-test pilot study with refugee youth (aged 16–24 years) (n = 120). Surveys were conducted before (t0), after (t1), and two-months following (t2) workshops. Among participants (mean age: 19.7 years, standard deviation: 2.4; n = 60 men, n = 60 women), we found significant increases from t0 to t1, and from t0 to t2 in: (a) PEP knowledge and acceptance, (b) bystander efficacy, and (c) resilient coping. We also found significant decreases from t0 to t1, and from t0 to t2 in sexual violence stigma and depression. Qualitative feedback revealed knowledge and skills acquisition to engage with post-rape care and violence prevention, and increased empathy to support survivors. Survivor-informed participatory comic books are a promising approach to advance HIV prevention through increased PEP acceptance and reduced sexual violence stigma with refugee youth. Trial registration: ClinicalTrials.gov identifier: NCT04656522.

Given the global growth of adolescent texting, we evaluate texting-based sexual communication as a potential site for interventions encouraging condom use cascades, particularly among displaced adolescents—a population with disproportionate levels of sexually transmitted infections, including HIV. With data from 242 forcibly displaced adolescents in the slums of Kampala, Uganda, we used path analysis to examine pathways from gender/dating relationship to condom determinant (knowledge of where to access condoms) and practices (access/use of condoms), through sexting-based condom negotiation, controlling for sexting practices. We found direct pathways from gender (boys vs. girls) and from dating relationship (dating vs. not) to condom determinant. Sexting-based condom negotiation partially mediated the pathway from gender/dating relationship to condom determinant, and fully mediated the pathways from gender/dating relationship to condom practices. Future digital sexual health interventions should consider the utility of texting-based applications in promoting knowledge and use of condoms among adolescents.

Background: Promoting sexual health among forcibly displaced adolescents is a global public health priority. Digital sexual communication strategies (eg, sexting) may increase adolescents’ confidence in discussing sexual health issues and negotiating condom use. However, limited evidence exists describing validated measures for text-based condom negotiation in the literature. Objective: This study helps fill this gap by adapting and examining the psychometric properties of a condom use experience through technology (condom use negotiated experiences through technology [CuNET]) scale. Methods: Using peer network sampling, 242 forcibly displaced adolescents (aged 16-19 years) living in Kampala’s slums were recruited for participation between January and March 2018. A subscale (embarrassment to negotiate condom use) of the Multidimensional Condom Attitudes Scale was adapted to incorporate sexting, yielding CuNET. Participants were randomly assigned to calibration and validation subsamples to conduct exploratory and confirmatory factor analyses to establish and validate the scale. CuNET measured participants’ support levels for texting-based condom negotiation via sexting based on gender, and multivariable logistic regression was used to explore its associations with sexual health outcomes (recent consistent condom use, access to sexual and reproductive health services, and lifetime sexually transmitted infection testing). Results: The one-factor CuNET with the validation sample was valid (χ24=5.3; P=.26; root mean square error of approximation=0.05, 90% CI 0.00-0.16; comparative fit index=0.99; Tucker-Lewis index=0.99; standardized root mean square residual=0.006), and reliability (Cronbach α=.98). Adolescent girls showed significantly lower levels of support for using sexting to negotiate condom use (mean 13.60, SE 0.70 vs mean 21.48, SE 1.23; P=.001). In multivariable analyses, a 1-point increase in the CuNET score was associated with increased odds of recent consistent condom use (adjusted odds ratio [aOR] 1.73, 95% CI 1.24-2.41) but not with access to sexual and reproductive health services (aOR 1.51, 95% CI 0.99-2.30) or lifetime sexually transmitted infection testing (aOR 0.90, 95% CI 0.64-1.26). Conclusions: The unidimensional CuNET scale is valid and reliable for forcibly displaced adolescents living in slums in Kampala, gender-sensitive, and relevant for predicting consistent condom use among urban displaced and refugee adolescents. Further development of this scale will enable a better understanding of how adolescents use digital tools for condom negotiation.

In the United States, SNAP was made available to refugees in 1977, and most refugees rely heavily on SNAP to sustain themselves before becoming self-reliant. Knowledge of sociodemographic factors and chronic debilitating conditions related to receiving SNAP benefits among refugees is limited. This study aimed to examine sociodemographic factors and chronic debilitating conditions associated with receiving SNAP benefits among refugees resettled in the United States. This study used a cross-sectional, nationally representative sample (n=6,100) of the refugees who entered the U.S. between 2013 and 2017. The data were obtained from the 2018 Annual Survey of Refugees (ASR) from participants aged 16 years or older who completed telephone interviews. The associations between receiving SNAP benefits (no/yes), and sociodemographic factors and chronic debilitating conditions were examined using logistic regression analysis. The main results showed that female gender, having an Iraq or Somalian refugee status, entering the United States between 2015 and 2017 or later, and having chronic debilitating conditions were associated with a higher likelihood of receiving SNAP benefits. Additionally, refugees whose English proficiency was "poor", aged 18 to 55 or older, unmarried, employed and resettled in the South, Midwest, or West were associated with a lower likelihood of receiving SNAP benefits. SNAP helps many refugees to receive nutrition assistance during their early resettlement phase. Participating in English and other empowering programs can lead to knowledge about available public programs, but limited English may slow integration and lead to lower income and continuous dependence on public programs, such as SNAP.