Focus groups in 11 Ugandan districts have identified a number of emerging and existing structural factors that are driving the country’s HIV epidemic.

In recent years a resurgence of HIV incidence in particular areas and among certain communities in Uganda has been reported. The causes for this are unclear but are suspected to be driven by complex structural factors, entrenched in the moral, social and cultural fabric of Ugandan society.

Study participants included men and women and came from a wide range of society – including opinion leaders, teachers, police officers, religious and political leaders, shopkeepers, elders and local residents.

Emerging drivers identified include the rapid urbanisation of rural Uganda, which has seen trading centres proliferate, and with them entertainment venues such as bars and discos where alcohol consumption is helping to drive high-risk sex.

Easy access to mobile phones and the internet was also cited as fuelling high-risk sex, particularly among young people, with participants describing how technology is being used to share pornography and as a way to connect to have casual sex.

Participants mentioned how the death of parents from AIDS-related illnesses had led to more child-headed households, causing young people to undertake sex work or transactional sex to survive. Participants also pointed to rising rates of unemployment among young people as resulting in an increase in the number of sex workers, particularly in border towns.

There was also an indication that HIV prevention messages have changed drastically, resulting in many people now perceiving HIV as a less dangerous condition than before, thereby lowering their sense of personal risk.

The study also suggests numerous structural drivers that have been present since the emergence of Uganda’s epidemic remain deeply entrenched, despite decades of HIV prevention programmes.

Many of these factors are highly gendered. For instance, intimate partner violence was cited by participants as one of the key factors fuelling the HIV epidemic, leaving women who are in abusive, sexually violent relationships unable to negotiate condom use or seek HIV services. Some participants described scenarios in which women felt trapped in abusive relationships because a dowry would have been paid to their family.

Because infertility is often blamed on the woman, many face pressure to seek treatment from traditional sources. But traditional healers, who tend to be men, often take advantage of this situation and prescribe sex with them as part of the remedy they are offering, say the participants.

Widespread HIV-related stigma and discrimination and negative attitudes towards condom use were also cited as persistent drivers. Traditional medical practices that use unsterilised equipment, and other traditional practices such as those associated with funerals ceremonies, where it is customary for a child to be conceived, also continue to leave many people at elevated risk of HIV infection.

All 11 districts included in the study have been selected for scaled-up HIV programmes, and these findings will be used to inform prevention interventions in each area.