Journal of Public Health Research 2015; volume 4:470

Original Article

Knowledge and behavioural factors associated with gender gap

in acquiring HIV among youth in Uganda
Shraboni Patra, Rakesh Kumar Singh
International Institute for Population Sciences, Mumbai, India

in 1998. By 1999, the HIV prevalence rate had been halved to 8.3%.2
Significance for public health The registered declines had been attributed to strict anticipatory
The present study represents the evidence of a recent increase in HIV infec- measures including condom use, public awareness raising campaigns
tion in Uganda from the latest round of AIDs indicator survey. This manu- and behaviour amend messages.3,4 But, the achievements of last two
script describes how young women (15-24 years-old) are disproportionately decades are getting eroded rapidly by the growing number of new
HIV-infected compared to young men in Uganda. They are more vulnerable infections. The country is trailing the fight against HIV/AIDS, with the
to HIV than young men. Moreover, it is also observed that young women are infection rates steadily rising. Uganda is among the few countries
at greater risk of acquiring HIV because of their risky sexual behaviour and where there are signs of an increase in unsafe sexual behaviours and
inappropriate knowledge of HIV transmission. Some educational pro- the number of sexual partners among youths. The number of women
grammes, growing gender equity in HIV/AIDS activities and services, drop- and girls living with HIV continues to grow fast.5
ping violence and coercion, addressing male norms and behaviours, improv- The increasing prevalence of HIV in Uganda during the last decade
ing women’s legal protection, and rising women’s access to income and pro- (7.5% in 2004-05 to 8.3 in 2011% among women and 5.0% in 2004-05
ductive resources can be very effective in minimising the vulnerability of
to 6.1% in 2011 among men of 15 to 49 year age) clearly shows that
young women to HIV/AIDS.
women and girls are disproportionately affected by HIV epidemic.6 In
Uganda, HIV infection cases begin to intensify in the age group 15-19
year and high in the 25-30 year age group. Girls, aged between 15-19
year, are two to six times more susceptible to be infected than boys of
Abstract that age by the end of 1999.7 The significant contributors to this trend
consist of early age at marriage, early age at first sexual experience,
Background. The increasing prevalence of HIV in Uganda during the low level of condom use, and a long alleged pattern of older men engag-
last decade (7.5% in 2004-05 to 8.3% in 2011 among women and 5.0% ing in sex with adolescents, particularly with girls to avoid contact with
in 2004-05 to 6.1% among men in 2011 of 15 to 49 years) clearly shows HIV.7 Uganda Demographic and Health Survey (2000-2001) reported
that women are disproportionately affected by HIV epidemic. Hence, that 11% of women aged 15-24 year had first sexual partner of 10 year
we assessed the prevalence of HIV and focused on differences in risky older than them.8 The higher rate of HIV transmission among women
sexual behaviour and knowledge of HIV among Ugandan youth. advocates either discrepancy in the rates of transmission between
Design and Methods. Uganda AIDS Indicator Survey 2011 data was women and men, higher rates of female sexual disclosure to infected
used. The total samples of men and women (15 to 24 years), inter- men, or longer survival among HIV-positive women compared to men.9
viewed and tested for HIV, were 3450 and 4504 respectively. The analy- The most shocking fact is that, women at their early reproductive span
are more infected with HIV, by risking their reproductive health, child-
sis of risky sexual behaviour was based on 1941 men and 3127 women
birth and health of their children.10
who had ever had sex and were tested for HIV. Pearson’s Chi-square
Furthermore, Ankrah observed that teenagers are at higher risk of
test and multivariate logistic regression analysis were used.
constricting AIDS because of socio-cultural pressures, physical matu-
Results. Findings showed that young women were almost two times
rity and behavioural factors including early commencing into sexual
more vulnerable than young men in acquiring HIV (OR=1.762,
activity, and the risk was aggravated by short-term relationships,
P<0.001). Women who had first sex under age 15 (7.3%), had more
repeated partner changes, multiple partners, low rate of condom use
than 2 sexual partners (9.2%) and did not use condom during last sex
and pessimistic attitudes.11 Hence, in this context it is imperative to
(6.4%) were more HIV-positive. Higher risk was found among women
study sexual behaviour in the different sections of the population, to
(6.3%) than men (2.2%). Significantly (P<0.01) less percentage understand the behavioural change, which is still the key approach to
(81.3%) of women as compared to men (83.8%) perceived that the controlling the outbreak of HIV.12
probability of HIV transmission may be reduced by correct and consis- Among Ugandan youth, some aspects of sexual behaviour may vary
tent use of the condom during sex. between the two sexes. It has been reported that roughly one-fourth of
Conclusions. Hence, there is an urgent need for effective strategies girls aged 15-19 year had their first sexual familiarity with someone
and programmes to raise awareness on sexual health and risky behav- who is 6 to 20 years older,13 whereas the comparable figure for boys of
iour, particularly targeting the youth, which will reduce the gender gap the same age group was 2 percent. This pattern of behaviour may have
in risky sexual behaviour and new transmission of HIV in Uganda. significant proposition for HIV transmission among female adoles-
cents and may be partially responsible for the difference in the preva-
lence of HIV among women and men. Further, in almost all African
societies, masculinity is associated with virility. A UNAIDS report
Introduction found that notions of masculinity encourage young men to view sex as
a form of conquest.14 In another study, it is found that among 15-19
Uganda, with HIV prevalence rate pointed at 18.5% in 1995, was the year olds, 28 percent of males and 27 percent of females believed that
foremost country in sub-Saharan Africa to reverse its epidemic.1 The a girl did not have the right to refuse sex with her boyfriend.15 Again,
prevalence rate of HIV infection was fallen to 16.3% in 1996 and 14.7% peer pressure of young men encourages to exercise their rights to

[Journal of Public Health Research 2015; 4:470] [page 101]

Article

multiple sexual partners, which signifies their power and masculinity, children under age 5, after obtaining a consent from their parents or
while for women it is being conditioned to submit to men’s leadership caretaker.6
and to accept men’s infidelity and polygamy. This is a grave concern, as The total samples of men and women (15 to 24 years age), inter-
young generation is more vulnerable to STIs and HIV (particularly on viewed and tested for HIV, are 3450 and 4504 respectively. Whereas, the
the first sexual encounter) due to possible abrasion and tearing of the analysis of risky sexual behaviour is based on 1941 men and 3127
immature reproductive tract. The level of engagement in high risk-sex- women who have ever had sex and were tested for HIV.
ual practices, specifically premarital sex and low condom use among
youth also contribute to the high prevalence of HIV.16 Moreover, alcohol Variables
intake, chewing of khat (a green leaf) or addicted to other drugs, smok- All the variables used in the analyses are discussed in two cate-
ing, low educational background, and being male are also found asso- gories: i.e. predictor variables and outcome variables.
ciated with having sex with multiple sexual partner.17 Predictor variables: The main predictor variables are re-coded for the
Since, it is at this period (i.e. age between 15-24 year) that young purpose of analyses, and for effective comparison with the results. The
person achieve the highest stage of cognitive and physical develop- important variable are sex, age group of young men and women, place of
ment, undergo behavioural changes, strive to define their self-identity residence, marital status, education level of men and women, wealth
and possess strong desire to explore sexual accomplishment,17 and in quintile, religion, ethnicity and region. Other important predictor vari-
a situation, when a country is hit by an increasing number of new HIV ables, related to risky sexual behaviour of youth, are age at first sex,
infection where women are disproportionately infected with HIV, it is number of sex partner, condom used at first sex, condom used at last sex,
important to focus on current situation and contributing factors of HIV consume alcohol during sex, higher risk sex (i.e. sex with a non-marital,
prevalence at the national level. Notably, growing difference in the HIV non-cohabiting partner), ever heard of AIDS, reduce risk of getting HIV:
prevalence among young men and women also requires in-depth do not have sex at all, reduce risk of getting HIV: have one sex partner,
research and attention of the researchers and policy makers. Hence, can get HIV from mosquito bites, can get HIV by sharing food with a per-
there is urgent need to address the current scenario of HIV prevalence son who has AIDS and Healthy looking person can have HIV.
among young men and women in Uganda, mainly focussing on their Outcome variables: Most important outcome variable is HIV preva-
different risky sexual behaviour, and level of knowledge and awareness lence, which is re-coded in yes and no.
of HIV transmission.
With this backdrop, the present study has attempted first time to Statistical analyses
assess the current prevalence of HIV among adolescents and youth (15-
Bivariate and multivariate analyses are used. Significance level of
24 year) according to their demographic and socio-economic character-
the bivariate association has been shown by Pearson’s Chi-square test,
istics and by their sex from the latest round of AIDS indicator survey in
whereas significance level of multivariate association is shown by
Uganda. Furthermore, the study has also tried to measure the differen-
binomial logistic regression analysis. Advantage of logistic regression
tials in the HIV prevalence by risky sexual behaviour, knowledge, and
analysis is that it requires no assumption about the distribution of the
awareness of HIV transmission among young men and women.
independent variables and the regression coefficient can be interpret-
Moreover, special attention is paid to understand the different risky
ed in terms of odds ratio (OR). In the present study, logistic regression
sexual behaviour and awareness of HIV transmission in association
model is applied to analyse the effect of selected socio-economic factors
with HIV status among youth from a gender perspective.
on men and women’s status of HIV. Therefore, binary logistic regres-
sion has been used to estimate the adjusted effect of background char-
acteristics as independent variables.
All the statistical analyses in the present study are performed by
Design and Methods
using the statistical package SPSS, version 20.
Data and sample
The study is based on data, sourced from Uganda AIDS Indicator
Survey (UAIS), 2011.18 The UAIS, 2011 is a nationally representative, Results
demographic, HIV serological survey. The survey was designed to
achieve national and sub-national estimates of the prevalence of HIV Distribution of sample
and syphilis infection as well as information about other indicators of
Table 1 represents the distribution of men and women samples by
programme coverage, such as knowledge, attitudes, and sexual behav-
their background characteristics. Among 7954 samples, 43.4% are men
iour related to HIV/AIDS. The Ministry of Health implemented the UAIS,
and 56.6% are women of age group 15-24 year. Among total samples,
2011. ICF International provided financial and technical assistance for
55.9% youths are 15-19 year old, whereas 44.1% are aged between 19
the survey through a contract with USAID, Uganda.
and 24 year. 22.7% of the total samples are from urban areas, whereas
The sample was allocated equally across all ten regions to allow suf-
77.3% are from rural areas. About 65% youths are never in a union,
ficient size to produce reliable estimates in each region. The survey
whereas about 30% youth are married and living with their partners.
used a two-stage sample design. The first stage involved selecting sam-
Percentage of women, who are widowed, divorced, separated or no
ple clusters from a list of enumeration areas (EAs) covered in the 2002
longer living together, is higher (6.6) than the men (2.3) sample with
Population Census. A total of 470 clusters was selected (47 in each
same status. Proportion of Catholic (about 39%) and
region), comprised of 79 urban and 391 rural points. The second stage
Anglican/Protestant (about 35%) is much higher in the total samples
of selection involved the systematic sampling of 25 households per
than the other religious groups. Mean of the total sample is 1.566, and
cluster from a list of households in each cluster that was produced by
the mean of the standard error is 0.006 (Table 1).
the Uganda Bureau of Statistics prior to the UAIS data collection. All
women and men aged 15-59 years who were either permanent resi- Gender differentials in HIV prevalence among youth
dents of the households in the sample or visitors present in the house-
hold on the night before the survey were eligible for interviews. All in Uganda
women and men who were interviewed were asked to give a blood sam- The present study has found considerable difference in the preva-
ple voluntarily for testing. In addition, blood samples were drawn from lence of HIV/AIDS among young men and women in Uganda. Huge gap

[page 102] [Journal of Public Health Research 2015; 4:470]

 Article

Table 1. Distribution of sample (15-24 year old) by background characteristics.

Background characteristics Men Women Total Mean SD SE
% N. % N. % N.
HIV 0.0369 0.1885 0.0021
Yes 2.1 73 4.9 220 3.7 7661
No 97.9 3377 95.1 4284 96.3 293
Sex 1.57 0.496 0.006
Men 43.4 3450
Women 56.6 4504
Age group in 5 years 1.44 0.497 0.006
15-19 59.6 2055 53.1 2393 55.9 4448
20-24 40.4 1395 46.9 2111 44.1 3506
Place of residence 1.77 0.419 0.005
Urban 21.0 724 24.0 1082 22.7 1806
Rural 79.0 2726 76.0 3422 77.3 6148
Marital status 0.3959 0.5776 0.0065
Never in union 82.6 2848 51.8 2332 65.1 5180
Married and living with partner 15.2 523 41.6 1875 30.2 2399
Widowed/divorced/no longer living together/separated 2.3 78 6.6 297 4.7 375
Level of education 1.41 0.625 0.007
No education 1.7 58 3.6 164 2.8 222
Primary 56.3 1944 59.0 2659 57.9 4602
Secondary 37.1 1280 32.9 1481 34.7 2761
Higher 4.9 168 4.5 201 4.6 369
Wealth index 3.29 1.424 0.016
Poorest 15.6 538 14.9 669 15.2 1207
Poorer 17.4 600 17.7 797 17.6 1397
Middle 19.3 667 17.5 789 18.3 1455
Richer 21.1 727 20.9 940 20.9 1666
Richest 26.6 919 29.1 1310 28.0 2229
Religion 2.4458 1.7742 0.0199
Catholic 39.8 1374 38.5 1734 39.1 3108
Anglican/protestant 34.6 1195 34.5 1552 34.5 2747
SDA 1.7 60 1.8 82 1.8 142
Pentecostal 5.9 202 8.3 373 7.2 575
Other Christian 3.2 112 2.5 111 2.8 222
Moslem 14.1 485 13.7 617 13.9 1102
Other 0.6 22 0.8 36 0.7 57
Ethnecity 6.6792 4.6521 0.0522
Baganda 17.3 598 18.0 811 17.7 1409
Banyankore 10.0 345 10.6 477 10.3 822
Iteso 6.8 236 7.0 317 7.0 553
Lugbara/Madi 4.4 151 4.6 208 4.5 359
Basoga 9.8 339 9.0 406 9.4 745
Langi 6.6 228 6.1 275 6.3 503
Bakiga 4.9 170 5.8 260 5.4 430
Karimojong 0.7 26 1.3 57 1.0 83
Acholi 4.0 139 4.4 198 4.2 337
Bagisu/Sabiny 8.0 275 6.0 272 6.9 547
Alur/Jopadhola 4.3 147 5.3 240 4.9 387
Banyoro 6.0 205 4.3 193 5.0 398
Batoro 4.3 147 3.6 163 3.9 310
Other 12.8 443 13.9 627 13.5 1070
Region 5.67 3.038 0.034
Central 1 10.2 351 10.8 486 10.5 837
Central 2 9.4 325 9.8 443 9.7 768
Kampala 8.9 307 9.4 422 9.2 729
East Central 11.5 396 10.1 457 10.7 852
Mid Eastern 12.3 424 10.1 454 11.0 878
North East 6.6 228 7.2 326 7.0 554
West Nile 5.8 199 6.0 268 5.9 467
Mid Northern 10.1 350 10.1 453 10.1 803
South Western 11.1 384 12.2 548 11.7 933
Mid Western 14.1 486 14.3 646 14.2 1132
Total 100.0 3450 100.0 4504 100.0 7954 1.566 0.496 0.006
SD, standard deviation; SE standard error.

[Journal of Public Health Research 2015; 4:470] [page 103]

Article

in HIV prevalence among men and women by their risky sexual behav- HIV/AIDS. Besides, 26.8% women and 28.5% men think that HIV can be
iour, and awareness and knowledge of HIV transmission is also spread through mosquito bites (Table 4).
observed. Young women are more HIV positive than young men are in
their early reproductive period (Figure 1).
From the bivariate analysis, it has been observed that, young women
are much more vulnerable to HIV infection than young men are, irre- Discussion
spective of their other demographic and socio-economic characteris-
tics. Women belonging to the richest wealth quintile (6%); Catholic and Uganda witnessed a significant decrease in HIV prevalence during
other Christian (5.5%) religion; Batoro (9.8%) and Langi (8.4%) ethnic the period of 1990-2000, because of the strict implementation of ABC
groups, and from Central-1 (8%) and Mid-Northern regions (6.8%) are model (i.e. Abstinence, Being faithful to one partner, and Condom
found to be more HIV positive than men. use).19 However, the fact is that, recently the prevalence of HIV in
The results of logistic regression analysis show that young women Uganda has been increased which has also raised the question of the
(4.9%) are almost two times more vulnerable than young men (2.1%) success of ABC model,6 as well as also indicates a wider gap in HIV
in acquiring HIV/AIDS (OR=1.762, P<0.001). HIV prevalence is signif- prevalence between men and women.
icantly higher among youth aged 20-24 year than youth aged 15-19 year The findings of the study show that on an average, HIV prevalence is
(OR=1.753, P<0.001). Prevalence of HIV is found higher among women 2.8 percent higher among young women (4.9%) than among young men
than men in all age groups, irrespective of the place of residence, mar- (2.1%) in Uganda. Further, high HIV prevalence, observed among well-
ital status, level of education and economic status. Women married and educated and wealthier women, is directly or indirectly more related to
living with their husband are significantly more (OR=1.591, P<0.001) economic status of women rather than their educational level. Similar
vulnerable to HIV than women who were never in a union. Further, findings also emerged from Berhan and Berhan’s study.20 Besides
women widowed or divorced or no longer living together or separated women’s physiologic vulnerability via heterosexual sex, several investi-
are significantly three times more (OR=3.234, P<0.001) at the risk of gators recognized unemployment and lack of education as revealing fac-
acquiring HIV than the women who were never in an union (Table 2). tors for women’s susceptibility to HIV infection as compared to men.21-24
The findings of the present study also replicate the same piece of evi-
Risky sexual behaviour and HIV prevalence among dence that uneducated and less educated women are much more vulner-
youth in Uganda able to HIV transmission than the higher educated women. Surprisingly,
The study has found increased prevalence of HIV among Ugandan women are becoming more HIV positive than men are, with the increase
youth associated with their higher risky sexual behaviour. Women are in their education level. It is also found that, women irrespective of their
significantly two times more (OR=2.578, P<0.001) likely to be HIV pos- marital status, are much more vulnerable to HIV than men.
itive for their higher risky sexual behaviour than men. Women who had The spread of HIV is mainly due to higher risk sex (UNAIDS, 2010). 25
their first sex at below 15 year’s age (7.3%); had more than two sex In a study, it was reported that HIV transmission among three-fourths
partners (9.2%, P<0.001) and did not use a condom during last sex of HIV positive women was through higher-risk sex.26 Similarly, the
(6.4%) are found to be more HIV positive than other groups of women present study shows that, HIV prevalence associated with high risk sex,
and men. Either partner consumed alcohol during sex (OR=1.509, is much greater among women than among men. For women, other
P<0.01, for men 6.2% and for women 6.9%), and women had higher contributors to this trend comprise early age at first sexual experience,
risk sex, i.e. had sex with a non-marital and non-cohabiting partner early age at marriage, low level of condom use, and a long-standing pat-
(6.3%) were very high threat to get HIV infected (Table 3). tern of older men engaging in sex with adolescents, particularly girls in
an attempt to avoid contact with HIV.1 In this respect, it is mention wor-
Gap in knowledge and awareness among young men thy that women’s economic empowerment has been proven to fail at
and women improving women’s bargaining positions when it comes to condom use.
The young women tend to focus on immediate problems such as pover-
From the bivariate analyses, a considerable gap in the knowledge ty and homelessness but not HIV prevention.27
and awareness of HIV/AIDS between young men and women is also
However, almost 98% Ugandan youth are aware of HIV, still there is
found. Results showed though 99% women and 97.9% men had heard
a gap between young men and women in terms of level of knowledge of
about HIV, still 14.2% women and 11.8% men think that HIV can be
HIV transmission and its prevention. Our research has shown that,
acquired by sharing food with a person who has AIDS. About 90.8% men
young women in Uganda are much more vulnerable to HIV prevalence
and 91.0% women of 15 to 24 year age think that the risk of getting HIV
by their unsafe sexual behaviour than young men are. We have found
can be reduced by not having sex with many partners. Significantly less
that women are much more exposed to higher risk sex than men.
percentage (81.3%) of women as compared to men (83.8%) think that
Several literatures have shown that real knowledge about conse-
always using a condom during sex can reduce the risk of getting
quences of unsafe sexual practice does not necessarily result in behav-
iour change and reduction in HIV and STI prevalence.28-30 Furthermore,
young women consumed alcohol during sex, are found to be more HIV
positive than young men. Hence, our findings are consistent with those
recent studies which showed that men and women who reported alco-
hol use during their sexual intercourse were likely to engage in unpro-
tected sex.31,32 Our study also shows that, women had more than 2 sex
partners, are more vulnerable to HIV than men. The reason behind the
practice of having multiple sexual partners could be to find social secu-
rity by adolescents women.26 Inconsistent condom use among Ugandan
youth in combination with multiple sexual partnerships often increas-
es the risk of HIV transmission.33 Here, it is mention worthy that
because of poverty, many youths in Uganda lack basic needs, and pover-
ty leads some youth, especially girls, to engage in survival sex, commer-
Figure 1. HIV prevalence among youth by sex in Uganda, 2011.
cial sex work, and early, sometimes forced marriages.34

[page 104] [Journal of Public Health Research 2015; 4:470]

 Article

Table 2. HIV prevalence (percentage) among youth (15-24 years) by their background characteristics, Uganda, 2011.
Background characteristics Men Women Both sexes Exp. β for HIV+
HIV + N. HIV + N. HIV + N. (95%CI)
Sex
Men° 1.0
Women 1.762 (1.308-2.307)***
Age group in 5 years
15-19° 1.7 2055 3.0 2393 2.4 4448 1.0
20-24 2.8 1395 7.1 2111 5.4 3506 1.753 (1.290-2.383)***
Place of residence
Urban° 1.7 724 5.9 1082 4.2 1806 1.0
Rural 2.3 2726 4.6 3422 3.5 6148 0.77 (0.499-1.193)
Marital status
Never in union° 1.7 2849 2.8 2332 2.2 5180 1.0
Married and living with partner 3.6 523 6.2 1875 5.6 2399 1.591 (1.135-2.230)***
Widowed/divorced/no longer living together/separated 7.6 78 13.1 297 12.0 375 3.234 (2.091-5.001)***
Level of education
No education° 0.0 58 3.1 164 2.3 222 1.0
Primary 2.3 1944 5.5 2658 4.2 4602 1.950 (0.828-4.594)
Secondary 2.0 1279 4.3 1481 3.2 2760 1.380 (0.565-3.373)
Higher 1.2 169 2.5 201 1.9 370 0.763 (0.245-2.375)
Wealth index
Poorest° 1.1 538 4.5 669 3.0 1207 1.0
Poorer 1.3 600 4.5 797 3.2 1397 0.902 (0.573-1.421)
Middle 3.6 667 2.8 789 3.2 1455 1.051 (0.657-1.680)
Richer 2.6 727 5.7 940 4.4 1666 1.439 (0.909-2.279)
Richest 1.7 919 6.0 1310 4.2 2229 1.365 (0.790-2.359)
Religion
Catholic° 2.5 1375 5.4 1734 4.1 3109 1.0
Anglican/Protestant 2.5 1196 4.4 1552 3.6 2748 0.931 (0.693-1,251)
SDA 8.3 60 2.4 82 4.9 142 0.928 (0.364-2.371)
Pentecostal 1.0 202 4.8 373 3.5 575 1.098 (0.677-1.779)
Other Christian 0.0 112 5.5 110 2.7 222 0.679 (0.289-1.591)
Moslem 0.4 485 4.5 617 2.7 1102 0.735 (0.478-1.129)
Other 1.5 22 4.9 37 3.2 57 0.925 (0.217-3.933)
Ethnecity
Baganda° 2.3 599 6.0 810 4.5 1409 1.0
Banyankore 2.9 345 6.7 477 5.1 822 1.497 (0.848-2.645)
Iteso 0.8 236 2.5 317 1.8 553 0.334 (0.119-0.939)**
Lugbara/Madi 1.3 152 1.4 207 1.4 359 0.751 (0.278-2.013)
Basoga 1.5 339 3.9 406 2.8 745 0.952 (0.483-1.875)
Langi 2.6 228 8.4 275 5.8 503 0.630 (0.195-2.030)
Bakiga 2.9 170 4.6 260 4.0 430 1.040 (0.506-2.136)
Karimojong 0.0 26 3.4 58 2.4 84 0.397(0.072-2.190)
Acholi 1.4 138 3.5 198 2.7 336 0.626 (0.193-2.030)
Bagisu/Sabiny 1.1 275 4.4 272 2.7 547 1.425 (0.664-3.058)
Alur/Jopadhola 4.8 147 4.1 241 4.4 388 1.469(0.722-2.990)
Banyoro 1.0 206 4.1 193 2.5 399 0.965 (0.472-1.971)
Batoro 2.7 147 9.8 163 6.5 310 1.889 (0.944-3.780)*
Other 1.3 3451 3.7 2381 2.4 1070 0.921 (0.561-1.514)
Region
Central 1° 4.0 351 8.0 486 6.3 837 1.0
Central 2 3.1 325 5.2 443 4.3 768 0.776 (0.467-1.291)
Kampala 0.3 307 5.7 422 3.4 729 0.555 (0.316-0.976)**
East Central 1.5 396 3.7 457 2.7 852 0.580 (0.287-1.171
Mid Eastern 1.4 424 1.8 454 1.6 878 0.316 (0.145-0.690)***
North East 1.3 228 3.7 326 2.7 554 1.102 (0.427-2.845)
West Nile 2.0 199 2.2 268 2.1 467 0.406 (0.167-0.985)**
Mid Northern 2.3 350 6.8 453 4.9 803 1.611 (0.510-5.091)
South Western 2.9 384 4.6 548 3.9 933 0.622 (0.332-1.167)
Mid Western 2.1 486 5.4 646 4.0 1132 0.580 (0.328-1.026)*
Total 2.1 3450 4.9 4504 3.7 7954
*P<0.05; **P<0.01; ***P<0.001; °reference category of different characteristics.

[Journal of Public Health Research 2015; 4:470] [page 105]

Article

Table 3. HIV prevalence among youth (15-24 years) who ever had sex and tested for HIV by risky sexual behaviour, Uganda, 2011.
Risky sexual behaviour Men Women Both sexes Exp. β for HIV+
HIV + N. HIV + N. HIV + N. (95%CI)
Sex
Men° 1.0
Women 2.578 (1.787-3.720)***
Age at first sex#
Below 15° 1.7 412 7.3 590 5.0 1002 1.0
15-17 1.9 893 6.1 1679 4.6 2572 0.861 (0.603-1.230)
18-20 3.0 558 5.8 761 4.6 1319 0.979 (0.654-1.465)
Above 20 2.6 77 0.0 62 1.4 139 0.365 (0.087-1.533)
No. of sex partner
0° 0.9 441 6.6 350 3.4 791 1.0
1 2.2 1156 6.1 2636 4.9 3792 1.067 (0.634-1.795)*
2 and above 4.1 344 9.2 141 5.6 485 2.036 (1.096-3.782)**
Condom used at first sex 5069
No° 2.6 1291 5.9 2061 4.6 3352 1.0
Yes 1.7 650 6.8 1066 4.9 1716 1.207 (0.888-1.640)
Condom used at last sex
No° 2.8 1006 6.4 2345 5.3 3351 1.0
Yes 2.4 494 4.9 432 3.6 926 0.804 (0.509-1.269)
No sex in last 12 months 0.9 441 6.6 350 3.4 791 -
Consume alcohol during sex
No alcohol used° 2.2 1327 6.2 2387 4.7 3714 1.0
Either partner was drunk 6.2 165 6.9 370 6.6 535 1.509 (1.025-2.223)**
Neither was drunk - 9 - 21 - 30 0.697 (0.094-5.182)
No sex in past 12 months 0.9 441 6.6 350 3.4 791 -
Higher risk sex§
Had higher risk sex° 2.2 1061 6.3 859 4.0 1756 1.0
Had sex but not higher risk 3.5 440 6.1 1918 5.6 2522 1.079 (0.752-1.548)
Not had sex in recent 0.9 441 6.6 350 3.4 791 -
Total 2.3 1941 6.2 3127 4.7 5068
Percentage not shown for fewer than 50 unweighted cases and values not available. *P<0.05; **P<0.01; ***P<0.001. °Reference category of different characteristics. #Excludes missing cases. §Sex with a non-marital,
non-cohabiting partner.

The only positive change in the high risk groups is the use of a con- times, women are getting infected by HIV due to negligence and
dom to prevent HIV epidemic. In this regard, regular use of condoms by forced sex by their partner and due to male domination over women’s
women also seems to be easily compromised when experienced a situ- sexual health and their reproductive rights. We need to remember
ation where their anticipated monetary gain is higher than their usual that the potential for the HIV pandemic depends on young people, and
earnings.1 Higher infection rates in women have significant implica- the need to scale up programs targeting this group is comprehensi-
tions for women’s health and survival of their children in Uganda and ble. Now, how they behave and how they’ll maintain their sexual
indicate the need for specially targeted interventions to reduce HIV lives, will determine the course of HIV pandemic in the future.37
transmission in this group.9 Therefore, persistent challenges to effective HIV prevention efforts
Therefore, it is high time to instigate and implement the program for adolescents and young people should include adequate access to
focussing the youth especially vulnerable women who are engaged in high-quality, youth-friendly HIV and sexual and reproductive educa-
higher risk sex, which extends but not limited to, unprotected sex (i.e. tion and health services, and diminish sexual violence against young
without use of condom), early sexual activity, especially before age 18, women and girls.
having multiple sex partners, unprotected mouth to genital contact
except in a long term monogamous relationship, and exchange of sex Recommendations
for drugs or money.35,36 Change in behaviour and spread of appropriate knowledge and
awareness of HIV/AIDS prevention are the fundamentals to control the
AIDS epidemic in Uganda. Youth should be involved in the intervention
design in order to ensure application of program to them. Similarly, the
Conclusions local governments, development partners, civil society organizations in
the region should involve youths. School-based programs can be effec-
The crucial factors contributing to high HIV prevalence among tive in improving youth’s knowledge of HIV/AIDS and reducing risky
Ugandan youths are the risky sexual behaviours which are substan- behaviour. Making health services more youth-friendly may lead to
tially different from men to women, and lack of proper awareness and increased use of facilities by young people in Uganda. Targeted media
existing knowledge gap between men and women with respect to and social marketing campaigns should be used in communities to
spread of HIV/AIDS. The fact needs to be addressed that despite hav- improve young people’s knowledge about HIV and AIDS. Promoting
ing proper knowledge to get protection from HIV infection, some- peer education i.e. training peers to be positive role models that can

[page 106] [Journal of Public Health Research 2015; 4:470]

 Article

Table 4. Comprehensive knowledge and awareness of HIV among youth (15-24years) by sex, Uganda, 2011.
Knowledge and awareness Men Women Both χ2
% N. % N. % N.
Ever heard of AIDS 15.241***
No 2.1 83 1.0 52 1.5 135
Yes 97.9 3398 99.0 4563 98.5 7961
Reduce risk of getting HIV: do not have sex at all 3.934
No 7.0 2374 8.2 384 7.7 621
Yes 90.3 306 89.2 4037 89.7 7101
Don’t know 2.7 97 2.6 142 2.7 239
Reduce risk of getting HIV: always use condoms during sex 9.060**
No 8.0 264 8.8 422 8.5 686
Yes 83.8 2850 81.3 3640 82.4 6490
Don’t know 8.2 284 9.9 501 9.2 785
Reduce risk of getting HIV: have 1 sex partner only, who has no other partners 22.340***
No 4.1 139 5.6 278 4.9 417
Yes 90.8 3082 91.0 4103 90.9 7185
Don’t know 5.1 177 3.4 182 4.1 359
Can get HIV from mosquito bites 10.346***
No 61.0 2086 60.4 2736 60.7 4822
Yes 28.5 961 26.8 1223 27.5 2184
Don’t know 10.5 351 12.8 604 11.8 955
Can get HIV by sharing food with person who has AIDS 12.772***
No 80.7 2753 77.5 3522 78.9 6275
Yes 11.8 405 14.2 656 13.2 1061
Don’t know 7.5 240 8.3 385 7.9 625
A healthy looking person can have HIV 8.216**
No 7.8 268 9.7 456 8.9 724
Yes 88.5 3005 87.0 3942 87.6 6947
Don’t know 3.7 125 3.4 165 3.5 290
Total 100 3398 100 4563 100 7961
*P<0.05; **P<0.01; ***P<0.001.

certainly influence young peoples’ behaviours, assisting access to and women who are on the verge of the risk of getting HIV require protection
creating a belief among young people. to reverse the feminization of HIV/AIDS. Some of the programmes can be
Moreover, the oversight of woman’s sexuality in Ugandan society that very effective in this regard, such as growing gender equity in HIV/AIDS
has increased the gender discrimination needs to be abridged. Vulnerable activities and services, dropping violence and coercion, addressing male
norms and behaviours, improving women’s legal protection, and rising
women’s access to income and productive resources.
Therefore, effective strategies and programs with the collaboration
Correspondence: Shraboni Patra, International Institute for Population of government and non-government organizations, targeting young
Sciences, Govandi Station Road, Deonar, Mumbai, 400088 Maharashtra, India. women, should be launched and encouraged to cut the rate of HIV
Tel.: +91.9321.504094 - Fax: +91.9967.561512. prevalence in Uganda. Moreover, proper monitoring and evaluation of
E-mail: [email protected] AIDS control programs is required to minimise the knowledge gap
Key words: Knowledge; sexual behaviour; gender gap; HIV; Ugandan youth. between men and women.
Acknowledgements: the authors would like to thank to MEASURE DHS+
(assists countries worldwide in the collection and use of data to monitor and
evaluate population, health, and nutrition programs) for providing the data.
Contributions: SP, conceptualization, data set preparation, analysis and manu-
script preparation and revision; RKS, correction of manuscript and revision. References
Conflict of interest: the authors declare no potential conflict of interest.
Received for publication: 29 November 2014. 1. Ntozi JPM, Mulindwa IN, Ahimbisibwe F, et al. Has the HIV/AIDS
Revision received: 24 March 2015. epidemic changed sexual behaviour of high risk groups in Uganda?
Accepted for publication: 25 March 2015. Afr Health Sci 2013;3:107-16.
©Copyright S. Patra and R. Kumar Singh, 2015 2. Ministry of Health. HIV/AIDS surveillance reports for June 1999,
Licensee PAGEPress, Italy 2000, and 2002. STD/AIDS Control Programme. Ministry of Health,
Journal of Public Health Research 2015;4:470
Uganda.
doi:10.4081/jphr.2015.470
This work is licensed under a Creative Commons Attribution NonCommercial
3. UNAIDS. Case study: A measure of success in Uganda. Geneva:
3.0 License (CC BY-NC 3.0). UNAIDS; 1998.
4. Low-Beer D, Stoneburner RL. Behaviour and communication

[Journal of Public Health Research 2015; 4:470] [page 107]

Article

change in reducing HIV: Is Uganda unique? Communicating AIDS 22. Higgins JA, Hoffman S, Dworkin SL. Rethinking gender, heterosex-
needs (CAN) project, centre For AIDS development, research and ual men, and women’s vulnerability to HIV/AIDS: time to shift the
evaluation. Afr J AIDS Res 2004;1. paradigm. Am J Publ Health 2010;100:435-45.
5. UNAIDS. Global Reports: UNAIDS reports on the global AIDS 23. Leclerc-Madlala S. Age-disparate and intergenerational sex in
Epidemic, 2013. Available from: http://www.unaids.org/en/media/ southern Africa: the dynamic of hyper vulnerability. AIDS
unaids/contentassets/documents/epidemiology/2013/gr2013/unaids_ 2008;22:17-24.
global_report_2013_en.pdf. 24. Njikam PR. Risky sexual behaviour, sexually transmitted infec-
6. Uganda Ministry of Health, ICF International. 2011 Uganda AIDS tions, HIV/AIDS and health promotion among students in the
indicator survey: key findings. Calverton: ICF International; 2012. University of Douala. Afr Popul Stud 2005;20:53-67.
7. Sekatawa E. Adolescent and the HIV/AIDS epidemic in Uganda. A 25. UNAIDS. 2010 report on the global AIDS epidemic. Joint United
briefing book for pathfinder international. Africa Regional Office; Nations programme on HIV/AIDS. Available from: http://www.
2000. Available from: http://pdf.usaid.gov/pdf_docs/PNADR257.pdf unaids.org/globalreport/Global_report.htm
8. Uganda Demographic and Health Survey. Reproductive health of 26. Centers for Disease Control and Prevention. HIV/AIDS surveillance
young adults in Uganda. A report based on the 2000-2001 survey. report 2007. Available from http://www.cdc.gov/hiv/topics/surveillance/
2002. Available from: http://dhsprogram.com/pubs/pdf/od23/od23.pdf 27. Saunders R. It takes two to tango: addressing the gender gap and
9. Berkley S, Naamara W, Okware S, et al. AIDS and HIV infection in HIV prevention programs in Nairobi, Kenya.
Uganda: are more women infected than men? AIDS 1990;4:1237-42. 28. Li C, Jha P, Stirling, B, et al. Sexual risk factors for HIV infection in
10. UNAIDS. AIDS by number. 2013. Available from: http://www. early and advanced HIV epidemics in Sub-Saharan Africa: system-
unaids.org/en/media/unaids/contentassets/documents/unaidspubli- atic overview of 68 epidemiological studies. PLoS One 2007;
cation/2013/JC2571_AIDS_by_the_numbers_en.pdf/. 2:e1001.
11. Ankrah EM. Adolescence: HIV and AIDS in Sub-Saharan Africa. 29. Upreti D, Regmi P, Pant P, Sinkhada P. Young people’s knowledge,
Presented at the workshop on Adolescent Reproductive Health in attitude, and behaviour on STI/ HIV/AIDS in the context of Nepal: a
Sub-Saharan Africa, the Centre for Development and Population
systematic review. Kathmandu Univ Med J 2009;7:383-91.
Activities (CEDPA); 1996. Available from: http://www.popline.org/
30. Doyle AM, Ross DA, Maganja K, et al. Long-term biological and
node/294818
behavioural impact of an adolescent sexual health intervention in
12. Konde-Lule JK, Sewankambo N, Morris M. Adolescent sexual net-
Tanzania: follow-up survey of the community-based MEMA kwa
working and HIV transmission in rural Uganda. Health Transit Rev
Vijana trial. PLoS Med 2010;7:e1000287.
1997;7:89-100.
31. Fritz K, Woelk G, Bassett M, McFarland W, et al. The association
13. Kaijuka EM, Kaija EZA, Cross AR, Loaiza E. Uganda demographic
between alcohol use, sexual risk behavior, and HIV infection
and health survey 1988/1989. Entebbe: Ministry of Health; 1989.
among men attending Beerhalls in Harare, Zimbabwe. AIDS
14. World Health Organization. Gender and HIV AIDs. 2003. Available
Behaviour 2002;6:221-8.
from: http://www.who.int/gender/documents/en/HIV_AIDS.pdf
15. Andersson N, Ho-Foster A, Matthis J, et al. National cross sectional 32. Simbayi LC, Kalichman SC, Jooste S, et al. Alcohol use and sexual
study of views on sexual violence and risk of HIV infection and risks for HIV infection among men and women receiving sexually
AIDS among South African school pupils. BM. 2004;329:952. transmitted infection clinic services in Cape Town, South Africa. J
16. Sacolo HN, Chung MH, Chu H, et al. High risk sexual behaviors for Stud Alcohol 2004;65:434-42.
HIV among the in-school youth in Swaziland: a structural equation 33. Choudhry V, Agardh A, Stafström M, Östergren PO. Patterns of
modeling approach. PLoS One 2013;8:e67289. alcohol consumption and risky sexual behavior: a cross-sectional
17. Alemu H, Mariam DH, Belay KA, Davey G. Factors predisposing out- study among Ugandan university students. BMC Publ Health
of-school youths to HIV/AIDS-related risky sexual behaviour in 2014;14:128.
northwest Ethiopia. J Health Popul Nutrit 2007;25:344-50. 34. Uganda AIDS Commission. Young people, health, HIV, AIDS and
18. Uganda Ministry of Health, ICF International. 2011 Uganda AIDS development: a case for Uganda, 2007. Available from: http://
indicator survey: key findings. Available from: http://health. hivhealthclearinghouse.unesco.org/sites/default/files/resources/U
go.ug/docs/UAIS_2011_KEY_FINDINGS.pdf ganda_young_people.pdf
19. Ekwaru JP. The effect of abstinence, being faithful to one partner, 35. Tross S, Hanner J, Hu MC, et al. Substance use and high risk sex-
and condom use (ABC) messages on HIV infection among youth in ual behaviors among women in psychosocial outpatient and
Uganda, 2012. PhD dissertation. University of California, Berkeley. methadone maintenance treatment programs. Am J Drug Alcohol
2012. Available from: https://escholarship.org/uc/item/274778g Abuse 2009;35:368-74.
7#page-1 36. Song Y, Ji C. Sexual intercourse and high-risk sexual behaviours
20. Berhan A, Berhan Y. A meta-analysis on higher-risk sexual behavior among a national sample of urban adolescents in China. J Publ
of women in 28 third world countries. World J AIDS 2012;2:78-88. Health 2010:32:312-21.
21. Holtgrave DR, Crosby RA. Social capital, poverty, and income 37. Diana N. knowledge, attitudes and practices of youth towards
inequality as predictors of gonorrhoea, syphilis, chlamydia and AIDS HIV/AIDS: a case of Northern Uganda region. Doctoral dissertation
case rates in the United States. Sex Transm Infect 2003; 79:62-4. University Institutional Repository, Kampala, Uganda, 2010.

[page 108] [Journal of Public Health Research 2015; 4:470]