Georgia State School of Public Health Ph.D. student Rachel Culbreth discussed her research into HIV and other diseases among young people living in slum communities in Kampala, Uganda, during the APHA 2016 annual meeting in Denver. This is her presentation.

1. Associated Risk Factors of Sexually
Transmitted Infections (STIs) and HIV Co-
Infection among Youth Living in the Slums
of Kampala
Rachel Culbreth, MPH
Monica H. Swahn, Ph.D.*
Laura Salazar, Ph.D.
Rogers Kasirye, M.A.
Presentation for APHA Annual Meeting 2016
Denver, Colorado

2. Funding Acknowledgment
• Research reported in this presentation was supported by the
National Institute on Alcohol Abuse and Alcoholism of the
National Institutes of Health under Award Number R21AA22065
(to Dr. Swahn).
• The content is solely the responsibility of the authors and does
not necessarily represent the official views of the National
Institutes of Health.
• Grant is funded as the development of a structural intervention
to delay underage alcohol use and prevent alcohol-related HIV
transmissions among youth in the slums of Kampala.
• There are no conflicts of interests to disclose

3. Presenter Disclosures
Presenter: Rachel Culbreth
The following personal financial relationships with
commercial interests relevant to this presentation
existed during the past 12 months:
No relationships to disclose

4. HIV Rates Worldwide
Source:
http://www.who.int/gho/hiv/en/.

5. • Uganda has a 6.5% HIV prevalence1
• Uganda is one of the few countries in sub-Saharan
Africa where rates are increasing rather than
decreasing2
• HIV rates are particularly high among youth living in
the slums of Kampala (13.9%) 3
HIV Rates: Uganda
Image: http://www.bbc.com/news/world-africa-14107906

6. HIV/STI Co-Infection
• STI co-infection is a serious concern among youth who
are living with HIV
• Estimated prevalence of STI co-infection among HIV+
persons is 11.3% in Africa3
• HIV+ persons may experience increased risk of mortality
from co-infection with certain STIs (hepatitis C) 4
• HIV/Herpes Simplex 2 virus co-infection associated with
higher detectable HIV viral load5
• Presence of STIs also increases risk of HIV acquisition6
Image: http://pulse.seattlechildrens.org/hiv-ribbon/

7. HIV/STI Co-Infection
• More research is needed to
investigate risk factors for co-
morbidities of HIV, particularly STI’s
• Knowledge of risk factors for HIV/STI
co-infection can further inform HIV
care and treatment for youth
• There are no studies, to our
knowledge, that examine risk
factors for HIV/STI co-infection
among youth living in the slums in
sub-Saharan Africa http://www.cdc.gov/actagainstaids/campaign
s/hivtreatmentworks/resources/infographics.
html

8. Research Questions
• What is the prevalence of HIV/STI co-infection
among sexually active youth in Kampala?
• What are the associated risk factors with HIV/STI
co-infection?
• Hypothesized risk factors (alcohol use, past 3-month
condom use, sex work)
• Sociodemographic variables (age, sex, education)

9. Overview of 2014 Cross-Sectional Study
• Cross-sectional study of Uganda
Youth Development Link (UYDEL)
youth conducted in March and April
of 2014 to quantify and describe
high-risk behaviors and exposures
• Convenience Sample (N=1134) of
urban youth living on the streets or
in the slums
• 12-18 years of age
• Tablet administered (30 mins)
• 91.6% participation rate
Approved by GSU IRB and
Uganda (UNCST)

10. Survey Administration
• The survey questionnaire was modeled from
the YRBS (CDC), the international Global
School-based Student Health Survey (WHO),
Demographic Health Survey.
• Survey questions addressed demographic
characteristics, family context, alcohol use,
alcohol marketing, violence and suicidal
behaviors, sexual behaviors, STDs and
HIV/AIDS.
• Surveys were administered by trained social
workers and peer educators. Data was
collected using electronic tablets.

11. Participant Demographic Characteristics
• 44% boys
• 46% were 16 years or younger
• 41% of participants households use 1 room for
sleeping
• 22% have lived on the streets
• 22% are orphans
• 35% Christian-catholic; 33% Christian other; 25%
Muslim

12. Methods
• Operationalization of Outcome:
• Presence of HIV/STIs self reported
• HIV: “Have you ever been told by a doctor/nurse or HIV
counselor that you have HIV?”
• STIs: “Have you ever been told by a doctor/nurse or HIV
counselor that you have a sexually transmitted infection such
as syphilis, herpes, bola bola, or gonorrhea?”
• Multilevel outcome: HIV/STI co-infection, HIV infection only,
STI infection only, No HIV/STI infection

13. • Operationalization of Independent variables:
• Alcohol use: past 12-month use
• Inconsistent condom use in the past 3 months
• Sex work self-reported as engaging in commercial sex
work
• Sociodemographic variables: age, sex, education
Methods

14. Data Analysis
• Only sexually active youth were included in the sample
(n=586)
• Descriptive statistics among HIV/STI levels
• Multinomial logistic regression analysis with 4-level
HIV/STI co-infection outcome
• Hypothesized risk factors (alcohol use, inconsistent
condom use in the past 3 months, and sex work)
• Controlling for demographic variables (age, sex, and
education)
• Pairwise comparisons were examined by inputting each
HIV/STI co-infection level as the referent group

15. Results
• 9.90% (n=58) reported HIV/STI co-infection
• 3.92% (n=23) reported HIV only
• 42.38% (n=251) reported STI only
• 43.35% (n=254) reported no infection
• Overall, 71.60% of youth living with HIV reported
co-infection with an STI

16. Descriptive Statistics among Youth
Demographic/ Risk
Factor Variable
STI Only
(n=251)
42.83%
HIV Only
(n=23)
3.92%
HIV/STI Co-
Infection
(n=58)
9.90%
Gender, n (%)
Male
Female
88 (35.06%)
163 (64.94%)
16 (69.57%)
7 (30.43%)
15 (25.86%)
43 (74.14%)
Age, n (%)
12-14 years
15-16 years
17-18 years
7 (2.79%)
60 (23.90%)
184 (73.31%)
1 (4.35%)
6 (26.09%)
16 (69.57%)
7 (12.07%)
11 (18.97%)
40 (68.97%)
Education, n (%)
Primary or less
Secondary or higher
143 (57.89%)
104 (42.11%)
9 (39.13%)
14 (60.87%)
35 (61.40%)
22 (38.60%)

17. Descriptive Statistics among Youth
Demographic/ Risk
Factor Variable
STI Only
(n=251)
42.83%
HIV Only
(n=23)
3.92%
HIV/STI Co-
Infection
(n=58)
9.90%
Past 3-month condom
use
No
Yes
66 (26.29%)
185 (73.71%)
11 (47.83%)
12 (52.17%)
21 (36.21%)
37 (63.79%)
Past 12-month alcohol
use
Yes
No
145 (57.77%)
106 (42.23%)
12 (52.17%)
11 (47.3%)
39 (67.24%)
19 (32.76%)
Engaged in sex work
Yes
No
45 (17.93%)
206 (82.07%)
1 (4.35%)
22 (95.65%)
17 (29.31%)
41 (70.69%)

18. Bivariate and Multivariable Analyses
Adjusted OR
STI only HIV only HIV/STI co-
infection
Gender
Male
Female
1.00
1.53 (1.04,, 2.25)
1.00
.42 (.16, 1.08)
1.00
2.01 (1.01, 4.02)
Age
12-14 years
15-16 years
17-18 years
1.00
2.18 (.81, 5.88)
2.08 (.80, 5.40)
1.00
1.60 (.17, 14.76)
.98 (.11, 8.44)
1.00
.54 (.16, 1.81)
.60 (.20, 1.81)
Education
Primary or less
Secondary or higher
1.00
.79 (.54, 1.16)
1.00
1.78 (.71, 4.49)
1.00
.73 (.39, 1.38)

19. Bivariate and Multivariable Analyses
Adjusted OR
STI only HIV only HIV/STI co-
infection
Past 3-month
condom use
No
Yes
.56 (.37, .83)
1.00
1.12 (.45, 2.78)
1.00
1.01(.52, 1.96)
1.00
Past 12-month
alcohol use
Yes
No
1.79 (1.21, 2.64)
1.00
1.86 (.75, 4.63)
1.00
3.00 (1.52, 5.89)
1.00
Engaged in sex
work
Yes
No
1.71 (.90, 3.25)
1.00
.79 (.09, 6.84)
1.00
2.97 (1.28, 6.88)
1.00

20. Discussion
• Nearly 10% of sexually active youth reported HIV/STI co-infection
• Nearly ¾ of youth who reported HIV also reported STIs
• This is nearly 7 times higher compared to the estimate of co-infection
with STIs among HIV+ persons in literature3
• Alcohol use was associated with STI only and HIV/STI co-infection
• Engaging in sex work was associated with HIV/STI co-infection
https://www.cdc.gov/std/hiv/

21. Limitations
• Self-reported HIV/STIs
• Convenience sample (hard-to-reach population)
• Future studies would benefit from obtaining
HIV/STI tests
• Type of STI could not be ascertained from this study

22. Implications
• Despite limitations, this is the first study to assess HIV/STI
co-infection among youth living in the slums of Kampala
• Future studies should further examine which types of STIs
are highly prevalent
• Preventative strategies should aim at increasing capacity at
HIV/STI testing centers
• Raising awareness of the complications of HIV/STI co-
infection is warranted
• Prevention initiatives should also target prevention of
alcohol use among youth

23. Uganda Youth Development Link’s
Response to HIV/STIs among youth
• HIV prevention center that provides counselling
• Child rights protection
• Alcohol and substance use programs
• Other adolescent sexual and reproductive health
programs

24. References
• 1. World Health Organization Global Health Observatory Data. Uganda
Country Data and Statistics. http://www.who.int/gho/countries/uga/en/.
• 2. UNAIDS. Gap Report.; 2014.
http://www.unaids.org/sites/default/files/media_asset/UNAIDS_Gap_report_e
n.pdf.
• 3. Swahn MH, Culbreth R, Salazar LF, Kasirye R, Seeley J. Prevalence of HIV
and Associated Risks of Sex Work among Youth in the Slums of Kampala. AIDS
Res Treat. 2016;2016:5360180. doi:10.1155/2016/5360180.
• 4. Weis N, Lindhardt BO, Kronborg G, et al. Impact of hepatitis C virus
coinfection on response to highly active antiretroviral therapy and outcome in
HIV-infected individuals: a nationwide cohort study. Clin Infect Dis Off Publ Infect
Dis Soc Am. 2006;42(10):1481-1487. doi:10.1086/503569.
• 5. Duffus WA, Mermin J, Bunnell R, et al. Chronic herpes simplex virus type-
2 infection and HIV viral load. Int J STD AIDS. 2005;16(11):733-735.
doi:10.1258/095646205774763298.
• 6. Holmes K, Sparling P, Stamm W, et al. Sexually Transmitted Diseases,
Fourth Edition. 4 edition. New York: McGraw-Hill Professional; 2007.

25. Questions?
Contact Information:
Monica Swahn, Ph.D.
Professor, Epidemiology
and Biostatistics
School of Public Health
Georgia State University
Atlanta, GA, USA
Mswahn@gsu.edu
404-413-1148