Cango Lyec (Healing the Elephant): HIV incidence in post-conflict Northern Uganda

Background: Civil war in Northern Uganda resulted in widespread atrocities, human rights violations, and death, and caused millions to flee to internally displaced persons camps. War-related traumas combined with difficulties accessing HIV prevention and health services has led to extreme HIV-related vulnerability among conflict-affected people who survived the war. Objectives were to (1) determine HIV incidence among conflict-affected people in Northern Uganda and (2) identify vulnerabilities associated with HIV infection. Methods: The Cango Lyec (Healing the Elephant) Project is a prospective cohort involving conflict-affected populations in three districts in Northern Uganda. In 2011, eight randomly selected communities were mapped, and a census was conducted. Consenting participants aged 13-49 years were followed over three rounds of follow-up. Longitudinal data collected included war-related experiences, sexual vulnerabilities, and sociodemographics. Blood samples were tested for HIV-1 at baseline and each 12-month follow-up. Multivariable Cox proportional hazard models determined factors associated with HIV incidence. Findings: Overall, 1920 baseline HIV-negative participants with at least one follow-up contributed 3877 person-years (py) for analysis. Thirty-nine (23 female, 16 male) participants contracted HIV during follow-up. Age- and gender-standardised HIV incidence rate was 10.2 per 1000py (95%CI: 7.2-14.0). Stratified by sex, the age-adjusted HIV incidence was 11.0 per 1000py (95%Cl: 6.9-16.6) among women and 9.4 per 1000py (95%CI: 5.3-15.3) among men. Adjusting for confounders, factors associated with risk of HIV included: having been abducted (HR: 3.70; 95%CI: 1.87-7.34), experiencing >= 12 war-related traumatic events (HR: 2.91 95%CI: 1.28-6.60), suicide ideation (HR: 2.83; 95%CI: 1.00-8.03), having >= 2 sexual partners (HR: 4.68; 95%CI: 1.36-16.05), inconsistent condom use (HR: 6.75; 95%CI: 2.49-18.29), and self-reported genital ulcers (HR: 4.39; 95%CI: 2.04-9.45). Interpretation: Conflict-affected participants who had experienced abduction and multiple traumas during the war were at greater risk of HIV infection. Trauma-informed HIV prevention and treatment services, and culturally-safe mental health initiatives, are urgent for Northern Uganda. (C) 2020 The Authors. Published by Elsevier Ltd.