Integrating an Alcohol and Violence Screening and Brief Intervention into HIV Post-test Counseling: Observations from a Ugandan Fishing Community on Lake Victoria

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RCCS, Ddimo, 2017

It was 11:00am on a hot July day. Inside a small green tent in a rural fishing village on the banks of Lake Victoria, an HIV counselor was speaking with two local women about a new study related to alcohol use and intimate partner violence. Outside, an intoxicated fisherman staggered around the tent, hollering unintelligible comments toward the women inside. The women looked at each other, smirked, and attempted to dismiss him before continuing with their work. While the irony of the situation was obvious – that the HIV counselor was conducting a study to reduce alcohol use – it also reinforced the importance of the work the team was doing here. I had arrived in Uganda one week earlier to support the implementation of a study that examines the best ways to reduce alcohol use and intimate partner violence in rural fishing villages on the banks of Lake Victoria. My two months working with researchers and clinicians in this area opened my eyes to many ways that local gender norms can play a direct role in determining women’s health outcomes.

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RHSP Tents, Ddimo, 2017

In 2012 a study showed about 52% of women and 62% of men in two other fishing communities on Lake Victoria reported getting drunk in the past month.1 From a study in a neighboring fishing village, HIV prevalence was around 37.1% in 2012, compared to the national average of 7.2%.2, Both violence and alcohol have been linked to increased HIV transmission and researchers have established that reductions in alcohol consumption and partner violence also decrease HIV burden. 3, 4, 5

Under the leadership of Dr. Jennifer Wagman, a team of researchers at UC San Diego are collaborating with Rakai Health Sciences Program (RHSP) to test the feasibility and appropriateness of an intervention that reduces harmful/hazardous drinking as well as intimate partner violence. Despite their well-established connection, this will be the first time that a combined alcohol and IPV intervention is embedded within an HIV testing and counseling setting. RHSP conducts yearly survey visits to these communities where they offer HIV testing, counseling, access to ARV treatments, and a small mobile clinic. This study is embedded during the counseling portion of these yearly survey visits.  The brief intervention gives both men and women the opportunity to talk about their experiences with alcohol abuse and relationship violence. The participant interviews are conducted in a safe, nonjudgmental, and private manner which allows participants to open up. While not all participants may be interested in talking about these topics, many show a sense of relief after sharing their experiences and a sense of gratitude for the education provided during the intervention.

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Part of my time in Uganda involved observing encounters with the participants and conducting interviews and a focus group discussion with the RHSP HIV counselors. I was able to learn about some of the cultural factors that lead to these high levels of intimate partner violence, alcohol use, and HIV infection. Up until this year, fishing has been one of the more lucrative careers in the area. With money comes access to two things—alcohol and women. 7 Due to a decrease in Lake Victoria’s fish populations and overfishing of the small, immature fish, a recent law has placed a lower limit on the weight and length of the fish that can be caught. While this has definitely limited the income in these areas, the alcohol and sex workers are still there and are unlikely to disappear any time soon.8

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Fishermen, Ddimo, 2017

There are many effects of alcohol, but a couple that are important to us are disinhibition and potential for aggressive behavior. When both men and women consume alcohol, they are more likely to practice risky sex or be coerced into unwanted or unsafe sex. Alcohol is also associated with angry and violent behavior in men, which can lead to IPV. This kind of tension and fear within a relationship can lead to unprotected and nonconsensual sex. With a limited or lacking police presence in these fishing villages, the widespread social acceptability of male dominance in a relationship, and the lack of options for economic independence, women are placed in a very vulnerable position.

In situations of IPV and alcohol abuse, women can suffer from both immediate emotional and physical damage as well as long term health problems. They can quickly lose control of their health and reproductive decision making, leaving them open to sexually transmitted infections and unwanted pregnancies. Unfortunately, the repercussions of alcohol use and violence can be even more severe in rural Uganda than in countries such as the U.S. While some treatments and tests are available in the region, they are frequently expensive and located far from these fishing villages. Women in the United States might have access to STI testing and treatment as well as psychological counseling. Here, the nearest facility that would offer good quality and relatively affordable care is in Masaka—a two to three hour motorcycle and taxi trip away. Since IPV is relatively acceptable in these communities, victims of violence often feel unable to talk about their experiences or receive any other social support. Other than syphilis and HIV testing provided by the Rakai Health Science Program, most people in this area do not have easy access to testing for other STIs.

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RCCS, Ddimo, 2017

While these are not direct effects of IPV and alcohol consumption, my experiences with clinicians in local hospitals and mobile clinics have shown me some of the unique downstream health challenges and risks that can face victims of IPV in these communities. In the cases of unwanted pregnancies due to IPV, a woman’s health can still be at risk even if she is able to reach a healthcare provider. For those women who are able to travel to the affordable government hospitals, it is the woman’s responsibility to bring gloves for the clinicians, blades to cut the umbilical cord, and their own plastic sheets to prevent contact with the less than sterile delivery beds. The delivery itself also comes with extra risks. Umbilical cords are tied with rubber strands torn off of gloves. If the baby emerges with the cord wrapped too tightly around its neck, there are almost never sterile clamps available to cut the cord – in these cases, women are forced to choose between having the newborn strangle, or risk transmitting unknown diseases from the use of dirty clamps. In the case of postpartum hemorrhage, the hospital relies on medical students to provide blood pressure cuffs. There is rarely any blood available in the blood bank and the oxytocin can be locked on the other side of the hospital complex. In the mobile clinics, many women come to receive treatments for various STIs. While the treatments are available, their male partners are often unwilling to undergo simultaneous treatment leading to an unfortunate cycle of reinfection. These challenges are present for all women who cannot afford the more expensive, private hospitals. However, the risks can be better controlled when a woman is allowed to decide exactly when and how she would like to have sexual relationships with her partner.
It is our hope that this screening and brief intervention has the potential to facilitate a change in favor of women’s rights and domestic safety in these communities. Given that this project has just started, we will wait for this, and future studies, to show just how effective and feasible it can be.

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Ddimo, 2017

-Eric

References:

1 Tumwesigye NM1, Atuyambe L, Wanyenze RK, Kibira SP, Li Q, Wabwire-Mangen F, Wagner G. Alcohol consumption and risky sexual behaviour in the fishing communities: evidence from two fish landing sites on Lake Victoria in Uganda. BMC Public Health. 2012 Dec 11;12:1069. doi: 10.1186/1471-2458-12-1069.

2 UNAIDS (2012) 2013 Uganda HIV and AIDS Country Progress report. Last accessed on September 7, 2014 from: AIDSinfo: http://www.unaids.org/en/dataanalysis/datatools/aidsinfo/

3 Alcohol use before sex and HIV acquisition: a longitudinal study in Rakai, Uganda (Zablotska et al., 2006)

4 Alcohol Use, Intimate Partner Violence, Sexual Coercion and HIV among Women Aged 15–24 in Rakai, Uganda (Zablotska et al., 2009)

5 “Intimate Partner Violence and Alcohol Fact Sheet” World Report on Violence and Health. World Health Organization

6 Iceta, Scovin. “Authorities Ban Sale of Sachet Waragi.” Daily Monitor, Daily Monitor, 9 Mar. 2017, http://www.monitor.co.ug/News/National/Authorities-ban-sale-of-sachet-waragi/688334-3843458-e7wcmxz/index.html.

7 Smolak, Alex. “A Meta-Analysis and Systematic Review of HIV Risk Behavior among Fishermen.” AIDS Care, vol. 26, no. 3, 2013, pp. 282–291., doi:10.1080/09540121.2013.824541.

8 “Bans on Fishing to Save Lake Victoria’s Fish Stocks.” The East African, 13 Mar. 2017, http://www.theeastafrican.co.ke/news/Bans-fishing-Lake-Victoria-fish-stocks/2558-3847516-10astq1/index.html.

Also published with the UCSD Center on Gender Equity and Health.

 

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