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Lost in transition : determining HIV prevalence and related vulnerabilities among young people surviving… Patel, Sheetal Harish 2012

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LOST IN TRANSITION:  DETERMINING HIV PREVALENCE AND RELATED VULNERABILITIES AMONG YOUNG PEOPLE SURVIVING ABDUCTION AND DISPLACEMENT IN POST-CONFLICT NORTHERN UGANDA   by Sheetal Harish Patel M.Sc., London School of Hygiene and Tropical Medicine, 2008 M.P.P., Simon Fraser University, 2006 B.A. (Adv.), The University of Manitoba, 2004  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  DOCTOR OF PHILOSOPHY in The Faculty of Graduate Studies (HEALTHCARE AND EPIDEMIOLOGY)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  August 2012  ? Sheetal Harish Patel, 2012  ii Abstract Background: Little is known about HIV infection and the related vulnerabilities of young people living in resource-scarce, post-emergency transit camps that are now home to thousands of IDPs following two decades of war in northern Uganda. This population in transition provided a unique opportunity to assess the influence of conflict on HIV infection among young people in post-conflict settings.   Methods: In 2010, a cross-sectional demographic and behavioural survey was conducted with a purposively selected sample of 384 transit camp residents aged 15 to 29, in two of Gulu District?s sub-counties. Biological specimens were collected for HIV rapid testing in-field and confirmatory laboratory testing. Multivariable logistic regression identified independent predictors for HIV infection among the sample and stratified by gender. Additionally, a bivariate analysis was conducted comparing HIV risk profiles of former abductees to non-abductees. Results: Of the 384 participants sampled, 192 (50%) were female and 107 (27.9%) were abductees. HIV prevalence was alarmingly high, at 12.8% overall; 15.6% among females; 9.9% among males, and; 12.1% among abductees. Sample sub-groups revealed no significant differences in proportions positive. The strongest predictor of HIV infection among young people was non-consensual sexual debut (Adjusted Odds Ratio [AOR]: 9.88, 95% Confidence Interval [CI]: 1.70, 18.06). Among females, having practiced dry sex was the strongest predictor (AOR: 7.62, 95%CI: 1.56, 16.95), and among males, non-consensual sexual debut was the strongest predictor (AOR: 3.24, 95%CI: 1.37, 7.67). Finally, in bivariate analysis comparing abductees to non-abductees, limited differences in risk profiles were demonstrated.  iii Conclusions: This study sought to fill a lacuna in epidemiological evidence and provide the Ugandan government and NGOs with the data necessary to inform timely and appropriate responses to HIV among young people in post-conflict transition. Study findings serve to recommend a gradual cessation of post-emergency aid and the design of interventions based on well-identified needs rather than circumstantial categorization. Additionally, development of population-specific responses sensitive to local contexts and sufficient to address the underlying causes of complex risk factors influencing the spread of HIV will reach beyond traditional prevention programming in a manner more effectively beneficial to young people in post-conflict settings.     iv Preface This statement is to certify that the work presented in this thesis was conceived, conducted, written, and disseminated by Sheetal Patel (SP). With advice from supervisors Dr. Patricia M. Spittal (PMS) and Dr. Martin T. Schechter (MTS) and committee members Dr. Noah Kiwanuka (NK) and Dr. Nelson K. Sewankambo (NKS), SP designed the studies and wrote the research protocols. In the field in northern Uganda, four Acholi research assistants (Stella Atim, Ketty Akello Otim, Samuel Lakor, Charles Ocaya Boya) and a nurse (Roselyn Lanyero), trained and supervised by SP, collected all data and specimens. With guidance and input from MTS, SP inputted the data and conducted the statistical analyses described in Chapters 4 through 6. SP conducted the literature review presented in Chapter 2. All chapters contained in this thesis were prepared and written by SP and reviewed by PMS, MTS, NK, and NKS. Chapters 4 to 6 were written as articles for submission to journals and versions of these chapters will be submitted for publication. This research received approval from the Providence Healthcare Clinical Research Ethics Board, Office of Research Services, University of British Columbia (Certificate number H10-00634). Approval was also granted from the Uganda National Council of Science and Technology (Reference number SS2384) and the Republic of Uganda, Office of the President (Reference number ADM 154/212/01).  v Table of Contents  Abstract .............................................................................................................................. ii Preface ................................................................................................................................iv Table of Contents ................................................................................................................v List of Tables ......................................................................................................................xi List of Figures.................................................................................................................. xiii List of Acronyms ..............................................................................................................xiv Acknowledgements............................................................................................................xv Dedication........................................................................................................................xvii Chapter  1: Background, Rationale and Objectives ..........................................................1 1.1 Background ..............................................................................................................1 1.1.1 History of the conflict in northern Uganda .........................................................1 1.1.2 Post-conflict transition context.........................................................................12 1.1.3 Young people, conflict, and HIV/AIDS............................................................15 1.1.4 Influence of conflict on HIV infection..............................................................17 1.1.5 Paucity of HIV-related epidemiology for northern Uganda...............................21 1.2 Rationale for Current Study ....................................................................................24 1.3 Study Objectives.....................................................................................................26 1.4 Overview of Dissertation ........................................................................................27 Chapter  2: Literature Review..........................................................................................29 2.1 Direct and Indirect Effects of War on HIV Transmission Among Young People.....29 2.1.1 Mass displacement and prolonged encampment ...............................................31  vi 2.1.2 Lack of information and access to sexual health and preventative services .......35 2.1.3 Gender-based violence .....................................................................................37 2.1.4 Summary .........................................................................................................41 2.2 After-Effects of War on HIV Epidemics and Young People....................................42 2.2.1 Summary .........................................................................................................47 2.3 Risk Factors for HIV Infection Among Conflict-Affected Populations in Northern Uganda............................................................................................................................48 2.3.1 History of IDP camp living ..............................................................................49 2.3.2 Child abduction................................................................................................49 2.3.3 Night commuting .............................................................................................51 2.3.4 Early and coerced sexual debut ........................................................................51 2.3.5 Traditional practice of dry sex..........................................................................53 2.3.6 Food security ...................................................................................................54 2.3.7 Mobility...........................................................................................................56 2.3.8 Alcohol use......................................................................................................57 2.3.9 Gender-based violence .....................................................................................58 2.4 Summary of Literature Review...............................................................................60 Chapter  3: Methodology ..................................................................................................61 3.1 Study Design ..........................................................................................................61 3.2 Sampling ................................................................................................................61 3.2.1 Site selection....................................................................................................61 3.2.1.1 Ongako sub-county ...................................................................................63 3.2.1.2 Awach sub-county.....................................................................................65  vii 3.2.2 Participant selection .........................................................................................68 3.2.2.1 Eligibility criteria ......................................................................................69 3.2.2.2 Response rate ............................................................................................70 3.3 Ethical Approval.....................................................................................................70 3.4 Study Team: Background, Training, Team Processes..............................................70 3.5 Permissions, Introductions and Community Preparation .........................................73 3.6 Recruitment and Consent Procedures......................................................................74 3.7 Data Collection.......................................................................................................76 3.7.1 Instrument translation process ..........................................................................76 3.7.2 Cross-sectional demographic and behavioural questionnaire ............................77 3.7.2.1 Pre-testing and review...............................................................................78 3.7.3 Biological specimen collection for HIV testing ................................................78 3.7.3.1 Rapid HIV testing .....................................................................................78 3.7.3.2 Confirmatory testing .................................................................................80 3.7.3.3 HIV testing algorithm................................................................................80 3.7.3.4 HIV testing protocol..................................................................................83 3.7.3.5 Storage and transport of specimens ...........................................................83 3.8 Return of HIV Test Results.....................................................................................84 3.8.1 Referrals to care...............................................................................................85 3.8.1.1 HIV care ...................................................................................................86 3.8.1.2 Trauma care ..............................................................................................86 3.9 Summary of Interview and Testing Process ............................................................87 3.10 Data Management and Analysis............................................................................88  viii 3.10.1 Data confidentiality and security, and quality control .....................................88 3.10.2 Overview of data analyses..............................................................................90 3.11 Data Feedback and Knowledge Translation ..........................................................91 3.11.1 Community/District level dissemination.........................................................91 3.11.2 International dissemination ............................................................................92 3.12 Study Timeline .....................................................................................................93 Chapter  4: HIV Prevalence and Correlates of Infection Among Young People in Post-Conflict Gulu District, Northern Uganda.........................................................................94 4.1 Introduction............................................................................................................94 4.2 Methods..................................................................................................................97 4.2.1 Study design and sampling...............................................................................97 4.2.2 Data collection.................................................................................................99 4.2.3 Explanatory variables.....................................................................................101 4.2.4 Statistical analysis..........................................................................................102 4.3 Results..................................................................................................................104 4.3.1 Sample characteristics....................................................................................104 4.3.2 Comparisons among HIV-positive and HIV-negative participants..................116 4.3.3 Prevalence and determinants of HIV infection................................................120 4.4 Discussion ............................................................................................................124 Chapter  5: Gender Differences in HIV Risk Behaviour Among Young Men and Women in Post-Conflict Gulu District, Northern Uganda ............................................133 5.1 Introduction..........................................................................................................133 5.2 Methods................................................................................................................137  ix 5.2.1 Sample...........................................................................................................137 5.2.2 Interview........................................................................................................137 5.2.3 Laboratory methods .......................................................................................138 5.2.4 Measures........................................................................................................139 5.2.5 Statistical analysis..........................................................................................140 5.3 Results..................................................................................................................141 5.3.1 Sample characteristics....................................................................................141 5.3.2 Proportion of HIV-positive participants by gender .........................................149 5.3.3 Predictors of HIV infection ............................................................................151 5.4 Discussion ............................................................................................................156 Chapter  6: Comparison of HIV-Related Vulnerabilities Between Formerly Abducted Child Soldiers and Non-Abducted Young People in Post-conflict Gulu District, Northern Uganda ............................................................................................................167 6.1 Introduction..........................................................................................................167 6.2 Methods................................................................................................................171 6.2.1 Participants and procedures............................................................................171 6.2.2 Statistical analysis..........................................................................................174 6.3 Results..................................................................................................................175 6.3.1 Sample characteristics....................................................................................175 6.3.2 Characteristics of abduction ...........................................................................178 6.3.3 Prevalence of HIV .........................................................................................181 6.3.4 Comparisons among abducted and non-abducted participants ........................183 6.4 Discussion ............................................................................................................193  x Chapter  7: Recommendations and Conclusions ...........................................................205 7.1 Summary of Study Findings..................................................................................205 7.2 Study Strengths and Unique Contributions............................................................208 7.2.1 Strengths........................................................................................................208 7.2.2 Unique contributions......................................................................................210 7.3 Limitations of Thesis Research .............................................................................211 7.4 Implications and Recommendations......................................................................214 7.5 Conclusions ..........................................................................................................222 Bibliography....................................................................................................................224   xi List of Tables   Table 1.1    Phases of post-conflict transition.......................................................................12 Table 3.1    Breakdown of site selection ..............................................................................63 Table 4.1    Socio-demographic characteristics of study participants..................................106 Table 4.2   Sexual behaviour characteristics of study participants ......................................110 Table 4.3    HIV/AIDS prevention practices and perceptions of risk of study participants..111 Table 4.4    Health status and service utilization practices of study participants .................114 Table 4.5    Comparison of socio-demographic and behavioural characteristics of HIV-positive and HIV-negative participants..............................................................................118 Table 4.6    Prevalence of HIV infection among study participants ....................................121 Table 4.7    Determinants of HIV infection by logistic regression ......................................123 Table 5.1    Comparison of socio-demographic and behavioural characteristics among female and male participants.........................................................................................................146 Table 5.2    Prevalence of HIV infection among female and male study participants..........150 Table 5.3    Comparison of socio-demographic and behavioural characteristics among HIV-positive and HIV-negative participants stratified by gender ...............................................153 Table 5.4    Determinants of HIV infection by logistic regression for male and female participants........................................................................................................................155 Table 6.1    Sample characteristics of participants (N=384) ...............................................176 Table 6.2    Characteristics of formerly abducted participants ............................................180 Table 6.3    Prevalence of HIV infection among study participants who were abducted and those who were not............................................................................................................182  xii Table 6.4    Comparison of socio-demographic and behavioural characteristics of formerly abducted and non-abducted participants stratified by gender .............................................188   xiii List of Figures  Figure 1.1    Map of Uganda..................................................................................................2 Figure 1.2    Complex relationship between HIV/AIDS and conflict....................................19 Figure 3.1    Algorithm for HIV testing ...............................................................................82 Figure 3.2    Timeline of study activities..............................................................................93   xiv List of Acronyms AIDS Acquired Immunodeficiency Syndrome GoU Government of Uganda HIV Human Immunodeficiency Virus IDP Internally Displaced Person LRA Lord?s Resistance Army NGO Non-governmental Organization OIF Operation Iron Fist STI Sexually Transmitted Infection UPDF Uganda People?s Defence Forces WFP World Food Programme         xv Acknowledgements I am deeply grateful to all the young men and women who participated in this study for sharing their stories, their hopes and their fears. Their candidness sharpened my understanding of what resiliency actually is. I also wish to sincerely thank my Acholi research team in Uganda for their invaluable insights, conviction and support, and for making Uganda my second home. Without both these groups of very important people, this study would not have been possible.  I offer my sincere and profound gratitude to my supervisors, Dr. Patricia Spittal and Dr. Martin Schechter, for each of their unique contributions to this dissertation and, in particular, for their guidance, wisdom and endless encouragement. I would also like to thank my committee members from Uganda, Dr. Nelson Sewankambo and Dr. Noah Kiwanuka, for their important contributions and assistance, and for pushing me to question more deeply. The ongoing mentorship I have received from each of these individuals is invaluable and I am very appreciative to have had the opportunity to be guided by such a supportive and experienced committee. I will forever be grateful to them. Funding for this research was generously provided by the Canadian Institutes of Health Research, the Michael Smith Foundation for Health Research, and the University of British Columbia. The Canadian Association of HIV/AIDS Research also kindly provided me with support so that I could attend their annual conference and present this research. I offer my enduring gratitude to my husband for his assistance in study initiation, for always making me feel safe in the field, both when he was there with me and when I was by myself, and for his unwavering love, support and encouragement throughout this process. I  xvi would also like to thank my family and friends for their constant support and endless patience throughout my PhD program.  Finally, I am enormously grateful to my mother and father, who have steadfastly supported me throughout my years of education, pushed me to always do my best, and taught me that nothing in life is impossible. I now understand why Uganda will always be your paradise.  xvii Dedication  To the strongest, sweetest, most courageous and resilient woman I know, my dear sister, Arti H. Patel  1 Chapter  1: Background, Rationale and Objectives 1.1 Background 1.1.1 History of the conflict in northern Uganda In November 2003, the United Nations? Under-Secretary-General for Humanitarian Affairs, Jan Egeland, described northern Uganda as ?the biggest forgotten, neglected humanitarian emergency in the world today? [Agence France-Presse, 2003]. For over two decades, from 1986 to 2008, northern Uganda experienced a brutal conflict between the Ugandan government and the rebel Lord?s Resistance Army (LRA) that was characterized by widespread displacement of peoples, indiscriminate killing and maiming of civilians, the abductions of thousands of children, and the destruction of the social and economic fabric of society. The International Criminal Court has classified these and related atrocities as war crimes. The Acholi sub-region of northern Uganda was the epicentre of LRA activities during the protracted conflict. This region spans an area of 28,500 square kilometres, equivalent to the size of Rwanda, and is now comprised of seven Districts [Finnstrom, 2008]. These Districts collectively support nearly a million and a half residents, of whom ninety-nine percent are of Acholi ethnicity and one percent originate from other tribes [Finnstrom, 2008]. The Acholi sub-region, or Acholiland as it is often referred to, is a vast and sparsely populated area with considerable agriculture and livestock development potential. The Acholi are traditionally a people of agriculturalists and livestock breeders and, therefore, ninety percent of them lived in rural areas prior to the conflict [Finnstrom, 2008].   2 Figure 1.1    Map of Uganda  ?Source, the United Nations, [2003], by permission.  3 Throughout Uganda's colonial period, from 1894-1962, British colonial administrators focused political and economic development in the south of the country [Finnstrom, 2008]. The newly created political economic order was led by the Bagandan people, while the Acholi, along with other northern ethnic groups, were conscripted into military service and supplied most of the country?s manual labour. However, as they comprised a majority of the military force, the Acholi retained an important power source. This power dwindled with the coup d?etat of Acholi General Tito Okello in June 1985 and was completely lost in January 1986, when the Acholi-dominated Uganda National Liberation Army was defeated by the National Resistance Army led by now-President Yoweri Museveni [Finnstrom, 2008].  Since 1986, when President Museveni took power in Uganda, the rebel factions that mobilized to resist his government have come to be characterized by transitions of increasingly vicious tyranny. A history of antagonism and distrust between the Acholi people of northern Uganda and southern-based tribes dominating the government contributed to the formation of the Lord?s Resistance Army (LRA) in 1987. It is led by Joseph Kony, the perpetrator of some of the most appalling human rights violations the world has ever seen.  The LRA purportedly aimed to overthrow the government, rebuild the Acholi nation and culture, and rule Uganda in accordance with the biblical Ten Commandments [LIU, 2003; Refugee Law Project, 2004; CSOPNU, 2004]. Even though Joseph Kony and the LRA professed to fight a spiritual war for the Acholi people against the Government of Uganda (GoU) and its military, the Ugandan People?s Defence Forces (UPDF), the majority of Acholi people did not respect or voluntarily assist the LRA. This repudiation can largely be attributed to the enhanced phase of terror inflicted upon the civilian population after the peace talks brokered by Betty Bigombe (the then Minister of State who was a resident of  4 Gulu District) in 1994 fell apart. Joseph Kony was not able to maintain the LRA?s numbers and when his regional support dwindled, he started stockpiling stolen food and abducting children to fill the ranks of his army. Mutilation, the planting of landmines, and the mass abduction of children as combatants became the LRA?s signature work, the insurgency of which directly targeted the civilian population and subsequently led to Kony?s loss of any remaining regional support. Hence, what had started out as a rebel movement to end the oppression of the north became an oppression of the north in itself. To this day, the facial mutilations of women who had their lips, ears and noses severed at gunpoint are visible in displacement camp settings.  When the peace talks failed in 1994, the Sudanese government allegedly began to support Joseph Kony [Finnstrom, 2008; Dolan, 2009]. By providing safe refuge in the form of encampments, land to cultivate, materials to build homesteads, hospitals for treatment of war-related injuries and even pharmaceuticals for treatment of common infections such as sexually transmitted infections (STIs), the Sudanese supported the LRA by enabling them to systemize their incursions into Uganda from protected base camps in the Sudan. To a large extent the Sudanese backing of the LRA in the form of weapons, ammunition and landmines among other supports, was the key factor in consolidating Joseph Kony?s reign of terror as the longest child hostage crisis in human history [Finnstrom, 2008; Dolan, 2009]. With a secure base in the Sudan and enough weapons, the LRA was able to systematically raid Uganda and grow their army via child combatants. By October of 1996 the casualty levels were high, the estimates of abducted children numbered close to five thousand, and the conflict had intensified, with rebel incursions becoming a normal part of daily life. Due to the focused efforts of the LRA, the GoU  5 facilitated the shift of villagers into Internally Displaced Peoples (IDPs) camps, and approximately 210,000 villagers moved from their homes into government-sanctioned camps [Dolan, 2009]. The villagers were given three days to move into ?protected? IDP camps, which were for the most part located around existing trading centres. Voluntary movement was not considered an option. By the year 2000, there were approximately 23 government-recognized camps in the region [Dolan, 2009]. At the time, most of the IDP camps were located in the Kilak, Aswa and Nwoya counties of Gulu District, as they were the most affected by rebel incursion.  In the wake of September 11th, 2001, and with increased pressure by the US government on Islamic states supporting terrorism, the Sudanese and Ugandan governments committed to improving bilateral relations. Part of this commitment included the Sudanese government severing support to the LRA, allowing the Ugandan government access to previously inaccessible territories, and temporarily suspending no-fly zones around Juba where the majority of LRA encampments were located. In March 2002, the Ugandan government launched ?Operation Iron Fist? (OIF), a military offensive against the LRA [Dolan, 2009]. Thousands of ground troops and air support, mainly in the form of helicopter gun-ships, were deployed. The government?s intention was to resolve the situation in the North using military force, and diminish the effects of what was becoming an international embarrassment for the government.   As the UPDF bombed encampments in the South Sudan, LRA rebels poured back across the Ugandan border and sought revenge against the civilian population with intensified attacks on communities, increasing abductions and forced recruitment. In the first two years of OIF the numbers of child abductions escalated; the number of abducted children under 18  6 years of age jumped from approximately 12,000 as of June 2002, to nearly double that by June 2003 and at least 30,000 by May 2004 [Nannyonjo, 2004]. More boys than girls were kidnapped and it is clear that the rebels were after children under the age of sixteen, whom they believed more likely to be HIV-negative [Spittal et al., 2008; Allen, 2006a; Annan et al., 2009; Beber & Blattman, 2009]. Although the precise number of abducted children during the conflict is unknown, evidence collected through the UNICEF-sponsored Survey of War-Affected Youth (SWAY) suggests that abduction has been grossly under-reported. Their estimates indicate that the LRA abducted approximately 66,000 young people between the ages of 14 and 30 [Annan et al., 2006; SWAY, 2008].  The IDP camps were targeted as bottomless reservoirs for potential abductees. Those families whose children could commute on foot to large urban centres daily, started to have their children sleep overnight in town. This night-commuting phenomenon, where thousands of children flocked from their villages to sleep in churches, hospitals, and on verandas in order to avoid abduction and other violence, is well documented [Falk et al., 2004; WCRWC, 2004]. At its peak in the spring of 2004, there were forty thousand children commuting every night. Children would walk several kilometres to town every night to sleep; in the morning they would walk back home, go to school, and then come back into town to sleep again. Various Non-Government Organizations (NGOs) responded to the crisis by organizing sleeping shelters in urban centres. There were five sleeping centres erected in Gulu town alone. At that time, NGO reports highlighted concerns about the sexual abuse/violence of girls as they moved unescorted from villages to the sleeping centres [Save the Children Uganda, 2004; SMEC, 2005]. A study by Spittal et al. [2008] conducted at the height of the LRA?s insurgency in northern Uganda, uncovered another ?night-commuting? trend that was  7 characteristic of the IDP situation and was of great concern. Girls and boys were moving away from their families? huts at dusk to sleep in other huts within camp perimeters. Many children were moving to circumstances where an older cousin was the only person providing supervision to a hut full of children, both girls and boys. The explanation for this ?internal? night-commuting by children in IDP camps is two-fold [Spittal et al., 2008]. First, when children were old enough to understand their parents? need for sexual privacy they traditionally did not sleep in their parents? hut but rather in their grandmothers? hut or the bachelors? hut [Ominde, 1952]. It appears that children were still following these cultural traditions in IDP camp settings. Second, if families were living on the periphery of the camp, their children were at increased risk for abduction by the very nature of the location of their hut. For security reasons, parents would attempt to negotiate a safe hut for their child to sleep in closer to the center of the camp. However, it was during this ?internal? night commuting when girls were most vulnerable to predation by men who would be offering food and clothing in exchange for sex [Spittal et al., 2008].  As LRA attacks and abductions increased, and Districts in northern Uganda previously relatively unaffected by the war became targets of the LRA?s insurgency, unprecedented numbers of people fled their homes and were displaced into IDP camps all over northern Uganda. The total number of people displaced and dependent on food-aid swelled. While in August 2001 there were an estimated 480,000 IDPs, by 2005 the total number of displaced persons had expanded to over 1.8 million, which accounted for over 90 percent of the population of the whole northern region [Republic of Uganda & WHO, 2005; Westerhaus, 2007; Mazurana & McKay, 2004; Fabiani et al., 2007a]. At that time, nearly 70 percent of the displaced population was under 25 years of age [WCRWC, 2004]. The health and  8 mortality survey of Internally Displaced Persons in May 2005 indicated that there were 53 IDP camps in Gulu District alone and that 80% of the entire population of the District was encamped [Republic of Uganda & WHO, 2005]. IDP camps, ranging in population size from 400 to 60,000 people, were generally characterized as squalid, severely overcrowded with little more than footpaths running between huts, unhygienic, lacking clean water and an adequate number of latrines, and highly devastated by abduction and disease [Dolan, 2009; Oxfam, 2008; Republic of Uganda & WHO, 2005; UNHCR, 2007; WCRWC, 2005; SMEC, 2005]. Health services were minimal and the camps were without essential infrastructures and were devoid of wage-earning opportunities. Camp residents were hungry, living in congested conditions and abject poverty, and forced into dependence upon NGO and donor-provided aid in the form of basic provisions. Consequently, the incidence of malnutrition, infectious diseases, violence and mental health issues in the north were documented as being much higher than national averages [Government of Uganda, 2007; Bolton et al., 2007]. With the majority of people in the northern region now in camps, an unintended consequence of OIF was the complete destruction of northern Uganda?s economic base, agriculture. Like many conflict-affected regions across Africa, Acholiland - once a very fertile region of the country - was left neglected, untended and uncultivated. Most IDPs no longer had access to their land for cultivation due to distance, curfew, total bans on mobility, and the risk of landmines or threat of being attacked by rebels should they attempt to go back home. This lack of access to their lands led to fundamental changes in the ways in which women and men led their lives and provided for their families. People were struggling or unable to assume traditional productive roles in agriculture, livestock management, hunting, and gathering [Dolan, 2009; Spittal et al., 2008; UNHCR, 2007]. This resulted in many  9 Acholi people becoming economically destitute and unable to successfully meet the needs of their families [Dolan, 2009; Patel et al., 2011]. Camp residents were now completely dependent upon food aid provided by the United Nations World Food Programme (WFP) with logistical support from the Norwegian Refugee Council. Each family received 75% of their nutritional requirements from the WFP, which made food deliveries once a month [Spittal et al., 2008]. Unfortunately, this food supply was intermittent and also insufficient in meeting basic daily nutritional requirements [SMEC, 2005]. As encampment persisted, international agencies steadily expanded their presence on the ground, building temporary schools and health clinics and providing other basic services in IDP camps. This humanitarian relief effort took place in an environment characterized by chronic insecurity, making technical support for programme delivery inconsistent and difficult to sustain. Despite the deployment of the Ugandan army to the camps, the LRA continued to terrorize the population. Government forces, too, were accused of committing human rights violations, with some perpetrators brought to trial and punished. The lives of displaced people in Acholiland remained consistently compromised by poverty, disease, hunger, fear of abduction and sexual violence. For child abductees, forced labour, forced killing and sexual slavery were a way of life in the bush until escape became possible. A study conducted by the Women?s Commission for Refugee Women and Children demonstrated that among children living in IDP camps, the idea of a ?safe passage? from childhood to adolescence to adulthood no longer existed [WCRWC, 2001]. Indeed, the erosion of cultural processes and belief systems that previously offered personal security and support to young people through familial and clan obligations was extensive [Patel et al., 2011]. Parents were understandably frustrated in terms of their loss of control over their  10 children and their ability to teach their children traditional values and practices that had sustained their people for generations [Spittal et al., 2008]. After years of intermittent peace negotiations, a new round of talks between the Ugandan government and the LRA opened in the southern Sudanese capital of Juba in July 2006. Shortly afterwards, in August 2006, the sides signed a landmark Cessation of Hostilities Agreement [Dolan, 2009]. Over the next two years, further agreements were reached on comprehensive solutions, reconciliation and accountability, and disarmament. However, despite this substantial progress, the LRA?s elusive leader Joseph Kony failed to appear in April 2008 for the signing of a final peace agreement, leaving a lingering feeling of uncertainty in the region. Although LRA activity has not been noted in northern Uganda since 2008, the LRA has since then presented a regional security threat, carrying out attacks in the Central African Republic (CAR), Sudan, and the Democratic Republic of the Congo (DRC) [IDMC, 2010]. A regional military offensive launched in December 2008, ?Operation Lightning Thunder?, failed to end atrocities by the LRA or capture its leader. Joseph Kony and his rebel force, the LRA, remain active today. Although the Juba Peace Process faltered at the final stage, it produced important agreements that, if implemented, could help build lasting peace. Above all, it ushered in a period of significantly improved security for the citizens of northern Uganda. The new, more secure, environment allowed the government to lift restrictions on freedom of movement. On November 10th, 2007, the GoU officially announced that the process of voluntary return had begun [WHO, 2007]. As a result, and as relative peace prevailed in the region, many IDPs began to return to their home villages. Starting in May 2008, the GoU issued a series of Guideline documents, including Camp Phase-Out Guidelines, followed in June of the same  11 year with the release of Guidelines for the Demolition of Abandoned Structures [OPM, 2008]. As of June 2008, close to 900,000 of the total estimated IDP population of 1.8 million had returned to their original villages, and some 460,000 had made the initial move to transit sites, smaller camps closer to return areas [IASC, 2008]. The Government of Uganda had established transit camps later in the war to move people closer to their land for subsistence and to decongest larger camps. These sites replicate original IDP camp structures and are inhabited as a ?first step? towards returning to pre-displacement home areas. By the end of July 2008, governing bodies of the IDP camps officially handed over their responsibilities to the Local Council (LC) system that characterizes local government for the rest of the country [IASC, 2008].  Near the beginning of the transition process, the GoU released the Peace, Recovery and Development Plan (PRDP) for northern Uganda, to assist in its transition from war to peace [Government of Uganda, 2007]. The PRDP was intended as a three-year framework to enable development and restore law and order in areas affected by conflict, in line with national standards. It had four strategic objectives: consolidation of state authority; rebuilding and empowering communities; revitalizing the economy; peace building, and; reconciliation. Priority actions included ?improving conditions and quality of life of the displaced persons? [Government of Uganda, 2007]. Unfortunately, lack of funding and oversight mechanisms delayed the implementation of the PRDP until 2009 [IDMC, 2010]. By late 2010, the design of monitoring mechanisms was being completed, and the PRDP was expected to run until at least mid-2012 with a total budget of approximately $600 million [UN OCHA, 2010a].  In addition to the PRDP, two government programmes of importance to the recovery of northern Uganda are the National Agricultural Advisory Services (NAADS) and the northern  12 Uganda Social Action Fund (NUSAF). The latter programme is managed by the World Bank and entered its second phase in January 2011 with a $100 million budget over three years [IDMC, 2010]. The cluster system for coordinating humanitarian action, established for the Acholi sub-region in early 2006, came to an end at the close of 2010 and all humanitarian coordination functions were handed over to the government [IDMC, 2010]. The Government of Uganda now holds the primary responsibility for recovery efforts in northern Uganda; this includes international responses.  1.1.2 Post-conflict transition context  The transition process in northern Uganda appears to have roughly three phases: pre-transition; early transition, and; late transition.  Table 1.1    Phases of post-conflict transition  People in pre-transition are still living in displacement camps and may experience barriers to return, causing stagnation in pre-transition. It has been observed that the vast majority of the population still living in IDP camps are ?extremely vulnerable individuals? (EVIs) including old and disabled people, and ?persons with special needs? (PSNs) [IDMC, 2010]. Besides extreme vulnerability or special needs, other factors hampering the return of these residual IDPs to villages of origin include: land disputes; inability to physically re-build in home villages; landmines and unexploded ordnance (UXOs); poor infrastructure, and; inadequate  13 basic services [UN OCHA, 2010b]. People in the early transition phase have made the initial move out of IDP camps to transit camps. They are moving back and forth between transit camp and village while re-building and may experience stagnation in this phase of transition due to land conflicts and/or lack of services and infrastructure in home villages relative to what is available in the transit camps, as well as ability to commute home on foot [UN OCHA, 2007]. The phase of late transition refers to people who have relocated permanently and are now living full-time in their rural village homesteads.  In June 2010 it was reported that a total of 108 of the 121 officially recognized IDP camps in the Acholi sub-region had been closed [UN OCHA, 2010b]. As of December 2010, more than 90 per cent of the 1.8 million internally displaced people who lived in camps at the height of the conflict have reportedly returned to their villages of origin while an estimated 182,000 IDPs remain in transit camps/sites closer to return areas [IDMC, 2010]. However, a succinct definition of ?return? as a one-way physical movement from IDP camp to village of origin does not appear to adequately capture the complexity of the returns process in northern Uganda and brings into question the authenticity of the numbers of people who remain in the early transition phase, yet to return permanently to their home villages [Oxfam, 2008]. According to the UN?s Consolidated Appeal for 2010, the situation of the 1.8 million people originally displaced and now in a process of transition cannot be characterized either as an end of displacement or the achievement of durable solutions. Vulnerability persists, which requires ongoing humanitarian assistance alongside effective recovery and development activities [UN OCHA, 2009]. The planning and implementation of re-settlement activities to support IDPs? transition and recovery have failed to keep pace with actual returns. Large recovery and development  14 programmes in northern Uganda have been delayed for long periods; confusion about funding between the government and development partners has persisted, and there has been a lack of coordination between the government, the donors, and the UN [IDMC, 2010]. Recovery facilitators have not been able to keep up with the pace of return, meaning that conditions in return areas are often worse than in the camps. A report by UN OCHA [2010c] notes that access to basic services has remained elusive to the majority of people in return areas with most IDPs returning to areas offering few basic services such as safe water, health care and education. Water and sanitation coverage has remained poor, with latrines accessible to only 31 percent of the population in the Districts of Pader and Gulu, and even fewer in the Districts of Lamwo and Amuru [UN OCHA, 2010c]. Inadequate health care infrastructures coupled with poor social service delivery in villages has already had alarming consequences and has left populations susceptible to epidemics. For example, in the Lango sub-region, where almost all former IDPs had completed their return by the end of 2007, the returnee population suffered an increase in malnutrition and mortality as a result of insufficient food and reduced access to basic services [CAP, 2008]. Furthermore, in October 2008, a persistent Hepatitis E epidemic was reported in Pader District, claiming many lives and infecting thousands. Lack of sanitation facilities and clean drinking water in return areas were cited as main contributors to the spread of Hepatitis E [IRIN, 2008; IDMC, 2010]. There is a high degree of mobility between villages, transit sites, and camps. Able-bodied people who remain in the IDP camps, as well as transit camp residents, often leave during the day to cultivate land in or near their home villages. A recent United Nations Office for the Coordination of Humanitarian Affairs (OCHA) study suggests that a majority of IDP camps are located less than 5 km or 50 minutes? walk from pre-displacement  15 residences, and transit camps are even closer [OCHA, 2007]. The close proximity of return sites to camps may make it an attractive option for people to return to farm in their original homes while maintaining a presence in the camps where services continue to be concentrated [OCHA, 2007]. Since services outside the camps are often poor, traffic also moves in the opposite direction. Residents of villages continue to visit camps in order to access basic services such as clean water and health care. The absence, or low quality, of schools in return areas is causing the separation of families as children are left behind to continue their education in camp schools, leading to serious child protection concerns. The perceived fragility of the current peace has also led some recent returnees to retain a residence in the camps as insurance against a resumption of the conflict, as most perceive the camps to be relatively safer than the more isolated return sites. The mobility of the population has blurred the distinction between IDPs and returnees, which in turn has complicated interventions by the government and by humanitarian agencies [Oxfam, 2008]. The current mobility patterns of returnees, coupled with the lack of basic services in return areas, leaves the sustainability of returns in post-conflict northern Uganda in doubt. Current and planned efforts notwithstanding, there is general consensus that it will take many years to rehabilitate northern Uganda [Oxfam, 2008]. 1.1.3 Young people, conflict, and HIV/AIDS As northern Uganda transitions into a post-conflict state and hope for the war-battered sub-region to return to normalcy rises, millions of young people born and raised in the camps are now generally considered a ?lost generation?; a generation of young people who have been traumatized by the violence of war, death, and depravity, and who are caught in a web of vulnerability exacerbated by the breakdown of family and the erosion of cultural norms  16 and social structures and processes that provided cohesion and guidance in the lives of previous generations. These ?lost boys and girls? are also at heightened risk for contracting HIV/AIDS [United Nations, 2001].  Young people are at the heart of the global HIV/AIDS pandemic. An estimated 11.8 million young people aged 15 to 29 are living with this disease. At least 50 percent of all new infections occur in this age group. Each day, nearly 6,000 young people become infected with HIV, the majority of them living in Sub-Saharan Africa [United Nations Children?s Fund, 2002a].  Furthermore, in Africa AIDS has increasingly targeted women. Over 50% of new HIV infections in Africa occur among women, with younger women being especially vulnerable [UNAIDS, 2001]. For example, of the estimated 530,000 Ugandans living with HIV in 2003, over half were women and girls [UNAIDS/WHO, 2004]; in 2002, six girls in Uganda were reported infected with HIV for every boy afflicted [Makerere University, 2003]. The primary means of HIV transmission among young people in Sub-Saharan Africa is sexual intercourse [STD/AIDS Control Programme, 2003].  The Declaration of Commitment on HIV/AIDS passed by the United Nations General Assembly (UNGASS) in June 2001 agreed that young people aged 15 to 29 are at highest risk of HIV infection and recognized that ?populations destabilized by armed conflict, including refugees, internally displaced persons and in particular women and children, are at increased risk of exposure to HIV infection? [United Nations, 2001]. As Mrs. Machel poignantly noted when releasing her infamous report to the UN on the impact of war on children,   17  ?War violates every right of the child with repercussions that could last a lifetime. [In times of conflict] not only are large numbers of children killed and injured, but countless others grow up deprived of their material and emotional needs, including the structures that give meaning to social and cultural life. The entire fabric of their societies ? their homes, schools, health systems and religious institutions ? is torn to pieces.? [Machel, 1996].  Recent reports demonstrate that Acholi young people have been particularly affected by war-related trauma and are suffering from the combined negative psychosocial and health effects characteristic of protracted bush wars and displacement camp living, including alcoholism, depression, and post-traumatic stress syndrome [Roberts et al., 2011; Ertl et al., 2011; Betancourt et al., 2009; Roberts et al., 2008; Bolton et al., 2007]. These young people born in the last 20 to 25 years know no other life than war. It is safe to say that the lives of Acholi young people have been irrevocably impacted by over two decades of war, traumatization and dislocation. The stark realities of young people in northern Uganda emerging from prolonged conflict and strife warrant special attention to their unique, post-conflict needs as the resettlement process continues in the region.  1.1.4 Influence of conflict on HIV infection While it is clear that the war has had onerous consequences for the health of the Acholi people, the specific influence of the war on HIV transmission remains unclear [Westerhaus, 2007]. Conflict analysts suggest that the relationship between HIV/AIDS and conflict is complex [Spiegel, 2004; Mock et al., 2004; Hanson et al., 2008; Jewkes, 2007; Westerhaus, 2007; Spiegel et al., 2007; Hankins et al., 2002]. On the one hand, factors that increase  18 conflict-affected populations? vulnerability are well documented and include: breakdown in social structures; lack of income and basic needs; sexual violence and abuse; increased drug use, and; lack of health infrastructures and education [Hankins et al., 2002; Khaw et al., 2000; International Rescue Committee, 2002; Save the Children, 2002; Smith, 2002; Spiegel et al., 2007; Mills et al., 2006; Jewkes, 2007; Donovan, 2002; Becker et al., 2008]. At the same time, however, factors that may decrease HIV transmission in conflict situations are rarely considered. These include: the reduced mobility and accessibility resulting from damaged infrastructures, which limits travel to high-prevalence urban areas; displacement to remote locations and surviving in the ?bush?, and; improved protection, health, education and social services provided by many refugee camps [Kaiser et al., 2002; Spiegel, 2004; Spiegel et al., 2007; Hankins et al., 2002; Mock et al., 2004]. The ultimate influence of all factors, both positive and negative, however, is dependent on: the pre-conflict HIV prevalence among the affected community; the HIV prevalence among the surrounding community for those who have been displaced; duration of conflict, and; the length of time the displaced population has resided in a particular camp [Spiegel, 2004; Hankins et al., 2002]. This information is summarized in Figure 1.2.           19 Figure 1.2    Complex relationship between HIV/AIDS and conflict                                               A survey of the literature provides examples of scenarios in which the relationship between HIV/AIDS and prevailing conditions during warfare presents different epidemiological patterns. In southern Sudan, Sierra Leone and Angola, all countries affected by protracted conflict, post-conflict HIV prevalence rates were lower relative to those of surrounding countries, many of which had not been in conflict. The lower prevalence suggests that armed conflict may have a protective effect in this regard, as a result of reduced mobility, accessibility and urbanization, disruption of sexual networks, and decreased casual consensual sex [Kedamo et al., 2003; Kaiser et al., 2002; Spiegel & De Jong, 2003]. Although sexual violence was reportedly high throughout the wars in all three countries, the  Key Factors ? HIV prevalence in area of origin ? HIV prevalence in surrounding host population ? Length of time in conflict ? Duration of displacement camp living  Increased Risk ? Behavioural change resultingfrom the breakdown of social structures ? Lack of income and basic needs ? Gender-based violence and transactional sex ? Lack of health infrastructure and education Decreased Risk ? Reduction in mobility ? Reduction in accessibility ? Increase in resources and services in host country  20 relatively low prevalence of HIV among the pre-war populations, and possibly among the paramilitaries, may not have been sufficient to accelerate HIV infection in the population [Spiegel, 2004]. Indeed, despite the increased risk of HIV transmission due to rape, as compared to consensual intercourse, as noted by Trisdale [2003], perpetrators must be HIV-positive to transmit the virus and the likelihood of this is low in a low-prevalence population [Spiegel, 2004]. In contrast to Sierra Leone, southern Sudan and Angola, increases in HIV infection among the general population in eastern DRC have been observed [Spiegel, 2004]. In this scenario, where ongoing hostilities appear to be increasing the spread of HIV, extensive sexual violence by paramilitary groups as well as foreign militaries, coupled with a breakdown of health services during the war, has primarily accounted for the increase in HIV infections [Save the Children, 2001; Wax, 2003]. However, Spiegel [2004] notes that many of the reports from the DRC are anecdotal and further studies are needed to confirm these results and properly assess the trends.  Due to the paucity of research in northern Uganda, it is unclear whether the conflict is directly associated with an increase in HIV transmission or whether it has provided a protective effect by keeping persons isolated and unable to access urban centres for years. While preliminary analyses obtained through Antenatal Care (ANC) sentinel surveillance demonstrated an initial increase in HIV transmission directly attributable to the war [Accorsi et al., 2004; Fabiani et al., 2007a; Fabiani et al., 2005; Fabiani et al., 2003], subsequent evidence indicated that pregnant women living in camp settings were significantly less likely to be HIV-positive than those residing in municipal areas (6.3% in camps vs. 11.6% outside of IDP camps) [Fabiani et al., 2007b]. However, findings from a study by Chamla et al.  21 [2007] suggested that the lower HIV prevalence among IDPs compared to non-IDPs, derived from ANC data, might actually be due to higher rates of AIDS-related deaths in the absence of access to effective Antiretroviral Therapy (ART) in the IDP camps. It is commonly argued (as reflected in the 2001 UNGASS commitment) [UN, 2001] that regardless of low prevalence or high prevalence, HIV-related vulnerability increases during conflict and rarely decreases after the conflict is over because of fundamental social changes that occur over time [Mock et al., 2004; UNHCR, 2006]. For example, some would suggest that heightened sexual violence against women and girls becomes normalized during protracted conflict and continues after the war is over [Ward & Marsh, 2006; Lowicki-Zucca et al., 2008]. Furthermore, increased exposure to HIV may be enhanced post-conflict because encamped populations are no longer as isolated and are free to move. This combination of high vulnerability and increased exposure opportunities post-conflict can lead to explosive growth in the HIV epidemic [Mock et al., 2004]. While it is unclear whether the conflict in northern Uganda has had either a protective or an enabling effect on HIV transmission, the potential for rapid progression of HIV infection in post-conflict northern Uganda warrants an aggressive and deliberate approach to evidence-based research and programme design as the previously encamped people resettle [Hanson et al., 2008]. 1.1.5 Paucity of HIV-related epidemiology for northern Uganda It has been acknowledged that similarly to other warfare-affected areas around the world, HIV/AIDS research has not been given high priority in northern Uganda [Westerhaus et al., 2007; Spittal et al., 2008; Hankins et al., 2002]. Instead, other public health crises and immediate life threatening illnesses (including Ebola and Cholera), resulting from war and displacement, have taken precedence. While priority has necessarily been placed on relief  22 efforts, Hanson et al. [2008] suggest that addressing HIV control is being considered increasingly important, both in the context of war and in its aftermath.  A portion of the UN Declaration of Commitment on HIV/AIDS passed in June 2001 calls for the development and implementation of national strategies that incorporate HIV/AIDS awareness, prevention, care and treatment into actions and programmes that respond to emergency situations [UN, 2001]. Although the National Strategic Framework (NSF) for HIV/AIDS Activities in Uganda published in 2000 [Government of Uganda, 2000] did not address the special circumstances of conflict-affected and displaced populations, the NSF for 2003-2006 [Government of Uganda, 2004] and the most recent National HIV/AIDS Strategic Plan (NSP) for 2007/8 ? 2011/12 [Government of Uganda, 2007] did allude to conflict-related concerns as an ?emerging issue?; however, the concerns were not fully addressed in the organizational framework delineated by strategy, activity area, and indicators. Nonetheless, this revision was an important step for displaced populations in northern Uganda as many NGOs and donor agencies use the NSF/NSP to inform their own fiscal and programmatic plans.  Despite the commitments made in the recent NSP and the new National Development Plan 2010/11 ? 2014/15 [Government of Uganda, 2010], HIV epidemiology for the northern regions of Uganda is severely limited when compared to inroads made in operational research in the rest of the country. In a study conducted in 2005 using ANC data, HIV prevalence in the entire northern region was estimated at 8.2%, with highest prevalence among women in the 20 to 29 year age group [Fabiani et al., 2007b]. This estimate was nearly double the national median HIV prevalence for rural areas of 4.7% [Ministry of Health, 2006]. When considering Gulu District alone (one of the hardest hit Districts in  23 northern Uganda) ANC data collected in 2000, 2003 and 2005 estimated age-standardized HIV prevalence to be 12.1%, 11.3% and 10.3% respectively [Accorsi et al., 2004; Fabiani et al., 2007a; Fabiani et al., 2005; Fabiani et al., 2003]. These rates may appear surprisingly low; however, the literature highlights the limitations of HIV prevalence rates derived solely from ANC sentinel surveillance data [Gray et al., 1998; Zaba & Gregson, 1998; Kaida et al., 2006; Mock et al., 2004; Strickler et al., 1995]. Relying exclusively on ANC data assumes similar access to and utilization of reproductive health and ART services among sexually active women of reproductive age both inside and outside of camps, which is not usually the case [Gray et al., 1998; Zaba & Gregson, 1998]. In addition, HIV-positive women may be less likely to access ANC care because of morbidity-related reductions in fecundity and incidence of pregnancy [Gray et al., 1998; Kaida et al., 2006]. Furthermore, and this is perhaps the most important limitation, ANC data omits men altogether and fails to capture any information on HIV prevalence in non-pregnant women, or in women who either do not attend clinics for pregnancy care or who receive ANC at facilities not represented in the surveillance system [Mock et al., 2004; Strickler et al., 1995]. One of the only other sources of epidemiological evidence for northern Uganda is the Ugandan Sero-Behavioural Survey, last conducted in 2004/05 [Ministry of Health, 2006]. HIV prevalence among young people aged 15 to 49 was estimated at 9 percent among young women and 7.1 percent among young men for the whole North Central Region, while the national average figures were 8 percent and 5 percent respectively. Overall prevalence in northern Uganda was 8.2%, the highest in the country and consistent with estimates derived from ANC data. However, these estimates have their own limitation, because HIV prevalence rates are reported regionally, and this makes it difficult to ascertain and compare  24 rates in the Districts most impacted by conflict, and therefore limits the opportunity for further analysis by sub-group.  While NGOs have consistently expressed grave concern that HIV/AIDS may be devastating the region, data that describes the unique legacy of the conflict on population health, including identifying which groups are the most vulnerable, was not captured in either antenatal studies or the most recent Uganda HIV/AIDS Sero-Behavioural Survey ? currently the only sources of HIV epidemiological data available for northern Uganda [Westerhaus, 2007]. Yet in 2005, the World Health Organization (WHO) and the Ugandan Ministry of Health reported an excess mortality of 1,000 people/week in the North, with AIDS as the second most common cause of death [Republic of Uganda & WHO, 2005]. With no data available reflecting the social, cultural and behavioural determinants of HIV in this complex setting, the causal factors of the current epidemic in the North remain undetermined. The lack of population-based data has frustrated many programme planners who have specific funds to allocate, but do not have the necessary evidence base needed to make informed HIV programming decisions and to evaluate the effectiveness of programming. It is clear that an epidemiological evidence base, providing the prevalence and determinants of HIV infection, is urgently needed for the design of effective HIV care and treatment programming as people continue to move back to their homes in northern Uganda. 1.2 Rationale for Current Study An analysis by the Uganda AIDS Commission and the Office of the Prime Minister in 2005 described the general picture of health services in all Districts impacted by the war in the North as one of poor access, uneven distribution, and poorly linked HIV care, treatment, and referral services [NACEAS Committee, 2005]. For Gulu District, the majority of HIV  25 prevention and care services (including ART, VCT and PMTCT services) were located within the municipality of Gulu town for the duration of the war, with only little and irregular outreach to the camps, leaving those encamped far from the town virtually without access to services [Chamla et al., 2007]. With the end of the conflict, the North was officially characterized as being in a period of ?recovery? and all initiatives and funding were to be distinguished as development-related activities. As a result, many NGOs focusing on ?emergency? relief, who previously supported HIV prevention and care activities, shuttered operations; this left significant gaps in HIV programming [P. Odong, personal communication, May 5, 2009]. Currently, the Districts are greatly challenged by the under-resourcing of health systems, the attrition of health personnel, and stock-out of medications. As northern Uganda moves from emergency and post-emergency into resettlement and repatriation processes, District officials are concerned that the causal factors of the epidemic could change quite rapidly. Also of great concern is the lack of funds available to integrate HIV planning activities into post-conflict development plans [P. Odong, personal communication, May 5, 2009]. The Government of Uganda has recently committed, through its ?National Peace, Recovery and Development Plan, to stabilize and rebuild the North. One of the primary objectives in this PRDP plan is to ?re-build and empower communities?; priority actions include ?improving conditions and quality of life of the displaced persons? [Government of Uganda, 2007]. In post peace accord transition it is common for regional and municipal planners to focus their re-development plans on governance and rebuilding infrastructure [Carballo, 2009]. However, it is critical to integrate and develop post-conflict HIV prevention and treatment interventions in tandem with the rehabilitation of primary care  26 programmes and facilities. For post-conflict HIV frameworks to be effective, an evidence base will be absolutely necessary. Without data it is difficult for the various facilitators supporting the peaceful transition of populations to prioritize effective responses.  As government, non-government, and international organizations embark on providing services to people moving back to their homes in the North, there is indeed an increased need for baseline HIV epidemiology and an investigation of the relationship between war-related experiences and HIV vulnerability [Hanson et al., 2008; Spiegel et al., 2007]. This study aims to address the paucity of HIV-related epidemiological evidence in post-conflict northern Uganda by providing a comprehensive account of HIV prevalence and related vulnerabilities among young people surviving displacement and abduction in Gulu District. Study results will contribute to the evidence base needed for the Government of Uganda and NGOs to support, inform and prioritize effective responses to HIV among young people in post-conflict transition. Moreover, understanding the distribution of HIV within this population, including analysis of the social, biological, and behavioural factors associated with infection, will offer new insights on HIV transmission in post-conflict settings. 1.3 Study Objectives The following study objectives and associated research hypotheses are addressed and presented in Chapters 4 to 6.  O1: To determine prevalence and correlates of HIV infection among young people aged 15-29 years in Gulu, northern Uganda, including the evaluation of risk factors and protective factors ? H1.1:  Young women will have higher HIV prevalence rates than young men ? H1.2:  Being in school will have a protective effect on HIV prevalence  27  O2: To analyze the risk of HIV infection in relation to gender and risk behaviour among young people aged 15-29 years in Gulu, northern Uganda ? H2.1: Young women will exhibit greater risk behaviour, including cross-generational and subsistence sex, than young men ? H2.2: Young women will report greater food insecurity and will exhibit greater risk behaviours for HIV infection than young men  O3: To determine the effect of abduction and living in the bush on prevalence of HIV and risk behaviours among former abductees aged 15-29 years in Gulu, northern Uganda ? H3.1: Young people who have experienced abduction and lived in the bush will have higher prevalence of HIV than young people who have not been abducted ? H3.2: Young people who have experienced abduction and lived in the bush will exhibit greater risk behaviour than young people who have not been abducted 1.4 Overview of Dissertation The current dissertation consists of seven chapters and takes an epidemiological approach to empirically address the three research objectives listed above. This material is presented in Chapters 4, 5 and 6; chapters 4 through 6 were written as articles for submission to journals and versions of these chapters will be submitted for publication. Three additional chapters are included in addition to the Introduction (Chapter 1). Chapter 2 provides a review of the research literature on conflict and post-conflict contexts and their relationship to individual level HIV risk among young people. Chapter 3 provides a detailed account of the methodology of the study, including study design, sampling procedures, data collection, and  28 analysis. Chapter 7 provides a summary of study findings from the three analyses presented in Chapters 4 through 6; it includes a discussion of the study?s strengths and unique contributions as well as its limitations, and offers over-arching insights and recommendations for policy and practice that are derived from the project as a whole.                      29 Chapter  2: Literature Review 2.1 Direct and Indirect Effects of War on HIV Transmission Among Young People There are approximately 26 million internally displaced people globally [Wessells & Edgerton, 2008]. These are people who have been forced to leave their homes due to violent conflict, violations of human rights and/or generalized violence, but have not crossed an international border and are therefore internally displaced within the borders of their home countries [UNHCR, 2008a]. Displacement often occurs as a result of conflict. The region most impacted by conflict and internal displacement is Sub-Saharan Africa (SSA). In 2008, there were active armed conflicts in 17 of SSA?s 47 countries [International Peace Research Institute, 2009], which resulted in an estimated 11.6 million displaced people [UNHCR, 2008a]. Approximately half of this population consists of young people aged 15 to 29 years [Wessells & Edgerton, 2008]. Sub-Saharan Africa is also a part of the world that has been hardest hit by HIV/AIDS. Nearly 23 million people there are infected with HIV, which accounts for 68% of the global total of HIV cases, yet SSA is home to just 12% of the world?s population [UNAIDS, 2011]. HIV infection is becoming endemic in SSA, with women and young people experiencing the largest burden of harm and adverse health outcomes due to both HIV infection risk and impact of war [UNAIDS, 2006, Spiegel, 2004].  Over the last two decades, wars and their related structural, economic and social factors have been viewed as significant mechanisms for the spread of HIV. In Angola, HIV had spread from the northern regions of the country to more central and southern regions by 1987, accompanying war-induced population displacement [Santos-Ferreira et al., 1990]. In Uganda, after the overthrow of Idi Amin in 1979, ethnic patterns of recruitment into Uganda?s National Liberation Army were positively associated with geospatial distributions  30 of AIDS cases in the country, according to data summarized in 1990 [Smallman-Raynor & Cliff, 1991]. Rwanda?s decade of war, disorder and the mass movement of refugees fleeing violence in the country supported an escalating HIV epidemic that by 1998 had spread from urban cities such as Kigali to rural villages [SMEC, 2005]. Finally, in Sierra Leone in 1999, reports demonstrating rapid increases in rates of STI and HIV during the country?s civil war were linked to preceding sexual contacts with foreign soldiers from countries with high HIV seroprevalence  [Salama et al., 1999].  Conflict epidemiologists suggest that it is not the presence of conflict per se that has a direct impact on rates of HIV infection, but rather that ?specific types of changes which might occur because of conflict? [McInnis, 2009] may lead to increased risk of infection [Hanson et al., 2008; Spiegel, 2004; Mills et al., 2006]. Mock et al. [2004] provide a useful framework for understanding the relationship between conflict and HIV. Mock discusses risk as being related to two types of factors: vulnerability factors that make individuals more susceptible to infection in general (i.e., poverty, malnutrition, lack of health services), and; exposure opportunity factors that make individuals more likely to be exposed to HIV (i.e., population movement, increased sexual violence and physical violence). It is only when both vulnerability and exposure opportunity are elevated that the general population is at an increased risk of infection [Mock et al., 2004].  A growing body of literature calls attention to the experience of children and young adults living in conditions of violent conflict. These reports demonstrate how young people are deeply impacted by the direct and indirect effects of war, including: combat violence; mass population displacement; the loss of, or separation from family members; the breakdown of social networks and social structures; high disease rates; psychological  31 wounds; economic devastation and poverty; food insecurity; the destruction of basic infrastructures; the weakening of health systems; strained governments and political dysfunction, and; the loss of opportunities considered necessary for healthy development and well-being, such as education and training in the skills needed to earn a livelihood [Hanson et al., 2008; Machel, 1996; Machel, 2001; Wessells & Edgerton, 2008; UNAIDS, 2001; Spiegel, 2004; Becker et al., 2008]. The risk that accumulates in such situations gravely increases young peoples? chances of being afflicted with HIV/AIDS and other STIs [Hankins et al., 2002; Mock et al., 2004].  Armed conflicts have traditionally been considered catalysts for HIV transmission due to three main factors: increased vulnerability and risks incurred by population displacement and encampment; lack of access to preventative and curative health services, and; associated sexual violence against women and girls [Ward & Marsh, 2006; UN Security Council, 1999; Spiegel et al., 2007; Mills et al., 2006; Jewkes, 2007; Donovan, 2002; Becker et al., 2008]. 2.1.1 Mass displacement and prolonged encampment Displacement In times of conflict, insecurity is ever-present, which in some cases causes affected populations to flee their homes. This displacement means the abandonment of valuable assets and livelihoods, loss of community, reduced social capital, and family separation. The dissolution of communities and family life can lead to the break-up of stable relationships as well as the disruption of social controls of sexuality, normally sustained by relatives and neighbours, governing men?s and women?s sexual behaviour [UNAIDS, 2001; Spittal et al., 2008; Patel et al., 2011; Seckinelgin et al., 2009; Becker et al., 2008]. This erosion of traditional mores in times of conflict increases the likelihood of risky sexual behaviours such  32 as early sexual debut, unprotected sexual activity, and larger numbers of sexual partners, all of which contribute to young people?s heightened vulnerability to HIV/AIDS [Hanson et al., 2008; Machel, 1996]. For example, in Rwanda, refugees lamented the breakdown of social structures and support networks during the war as this made their workloads greater, their situations lonelier, and their personal safety more fragile [SMEC, 2005]. Moreover, refugees commented that the institution of the family and community had been so much destroyed by war, displacement, and encampment that it was now no longer possible to rely on the social support of neighbours and clan members. This loss of social capital and dissolution of traditional societal norms during the conflict in Rwanda was blamed for the observed increase in drunkenness, infidelity, and the number of rape and incest cases. Similarly, in Burundi, displacement during conflict has been a key factor in upsetting family and social structures. The loss of regulatory social institutions, occasioned by the split of families and the loss of ?the concept of society?, was blamed for the failure to have in place appropriate measures for combating serious social excesses such as drunkenness, multiple sex partners, rape and defilement, all experiences related to the spread of HIV infection [Seckinelgin et al., 2009]. Furthermore, a study by Spittal et al. [2008] indicated that in IDP camps in northern Uganda, prolonged conflict and mass displacement in the region had largely eroded traditional Acholi mentoring and belief systems that had previously served to protect adolescent girl?s sexuality; it was suggested that this breakdown of family and social structures had contributed to adolescent girls? heightened sexual vulnerability and subsequent enhanced risk for HIV/AIDS [Spittal et al., 2008; Patel et al., 2011].    33 Encampment Displacement often entails prolonged periods of encampment. This encampment encompasses a further layer of structural factors that influence the vulnerability of conflict-affected populations to the spread of HIV/AIDS. Such factors include congested living conditions and poverty, lack of livelihood opportunities, and dependency on relief aid. The resultant high-risk sexual behaviours are direct pathways to the transmission and infection of HIV in these populations [UNHCR, 2007; WCRWC, 2005; Bolton et al., 2007; UK Consortium on AIDS & International Development, 2002].  Congestion One of the features of encampment that contributes to the high-risk sexual activity associated with the potential spread of HIV is congestion. Congestion within IDP and/or refugee camps during conflict comes about as many people are housed on a limited piece of land. As natural increase takes place, with children growing and new arrivals entering, more land is required but is rarely available. Sexual relationships during wartime are likely to be short-term and thus more frequently formed with different partners. Frequent partner change can foster the reproductive rate of the HIV epidemic both directly and, indirectly through an increase in STI risk, which further increases HIV transmission [Anderson et al., 1991; Anderson et al., 1990; Fleming & Wasserheit, 1999]. In Angola, for example, extremely over-crowded and congested camps were reported to lead to rape and defilement, prostitution, and poverty, with resultant increased vulnerability to HIV infection [De Jong, 2003].  34 Poverty, lack of livelihoods and dependency on food aid In addition to being severely congested, camp environments are often characterized as devoid of wage-earning opportunities, leaving camp residents living in abject poverty and forced into dependence upon NGO and donor-provided aid of basic provisions [Dolan, 2009; Oxfam, 2008; Republic of Uganda & WHO, 2005; UNHCR, 2007; WCRWC, 2005; SMEC, 2005]. Poverty certainly emerges as an overarching factor influencing the spread of HIV in refugee and IDP environments, underpinning the sexual risks that women and girls take to obtain needed resources [Machel, 1996]. The principal dimensions of poverty in times of conflict include: the inadequate supply of basic essentials for the family, including food; the limited livelihood opportunities through which to gain these essentials, and; the loss of the traditional role of men as the providers in the household. The struggle to survive within this environment where women face increased responsibilities for family upkeep, compels women and girls to trade sex in exchange for food, water, shelter, protection and other basic commodities for themselves and their children [Chelala, 1990; Hankins et al., 2002, Jewkes, 2007]. Under these circumstances women are automatically vulnerable to potential financial and sexual exploitation by those who have access to food or money, most commonly men from their camps, camp committee members, traders, NGO workers, civil servants, and military and rebel soldiers [SMEC, 2005; Spittal et al., 2008]. The economic destitution of war-affected populations no doubt increases their HIV risk behaviours, and this is particularly the case for women and girls.  It is important to note that a means of livelihood that is a constant in camp settings is the brewing and selling of beer and spirits, and this is usually a relatively good source of income for middle-aged women whose husbands are not present, although it, too, has risks. For  35 example, it was reported by Adelekan [2006] that widows who make local beer in the Kakuma refugee camp in Kenya are often also expected to provide ?regular customers? with sexual services.  Furthermore, it has been reported that the abject poverty experienced by forcibly displaced and encamped populations during times of conflict, coupled with the general absence of work-related activities and a resultant dependency on food aid, have combined to increase alcohol consumption, contributing to high levels of risky sexual activity [Kintu et al., 2007; Oxfam, 2008]. In refugee camps in Rwanda and IDP camps in northern Uganda, a lack of engagement in productive activities was reported to lead to increased alcohol consumption, which in turn led to impaired judgment and the resulting risky sexual behaviour [SMEC, 2005]. Basically, men, including youth, used sex as a way to ?kill time?. The association between lack of livelihood, idleness and risky sexual behaviour is particularly pertinent for young people, who bear the heaviest economic burdens during and after wartime [WCRWC, 2001]. In addition, with educational opportunities limited in general in times of conflict, schools rendered inhabitable, a lack of teachers, interrupted studies due to abduction, and a myriad of other barriers that keep children from accessing a consistent and stable education, large groups of young people remain unoccupied during the day. There is no doubt that a camp lifestyle with little engagement in productive activities aggravates the spread of HIV among young people [Kintu et al., 2007].  2.1.2 Lack of information and access to sexual health and preventative services  During conflict, low awareness of HIV/STIs, lack of information about and access to HIV/STI prevention supplies, and non-existent or weakened prevention programming combine to create conditions ripe for HIV transmission [Hankins et al., 2002; Becker et al.,  36 2008]. In addition, access to general sexual health information, treatment of STIs, care for victims of sexual abuse, preventative health services (including HIV testing), and continued access to condoms are all limited [SMEC, 2005; Hankins et al., 2002; Patel et al., 2011]. In a study of knowledge levels, perceptions, and attitudes towards contraceptive use among 208 young people living in refugee camps in Nigeria, most respondents had limited accurate information about contraceptives. Nearly half of all respondents had misperceptions about the safety of contraceptives, believing that condoms are dangerous and that chemicals in oral contraceptives could damage their reproductive system. Such beliefs have resulted in extremely little use of contraceptives and condoms, and the many unintended pregnancies and increased sexual vulnerability and risk of HIV infection that result in turn [Okanlawon, 2010]. In a report by SMEC [2005], many female respondents in IDP camps in the DRC reported suffering from vaginal discharge and pain on urination. However, lack of money for transport to the nearest health centre kept them from accessing treatment, and this left them at high risk of contracting HIV while at the same time spreading the STIs most likely responsible for their symptoms. The general instability prevalent in times of conflict diminishes opportunities for NGOs and other organizations providing prevention programming to maintain a strong, consistent presence in displacement camps [Hanson et al., 2008; WHO, 2007; UNHCR, 2006; Spittal et al., 2008]. For example, in Awer IDP camp in northern Uganda, HIV/AIDS programmes were run by NGOs based in Gulu town, 23 km away on an insecure road, and therefore the provision of these programmes was intermittent depending on the state of the road?s security at any given time. Free condoms were sporadically available from the health unit in Awer, when the road was secure enough to deliver supplies, but only male youth were brave enough  37 to approach health unit staff and ask for condoms [SMEC, 2005]. Combinations of circumstances such as these indicate that the sexual health needs of displaced people are often not met in conflict settings, increasing their risk of HIV infection [Ministry of Health, 2001]. Research demonstrates that reduced access to reproductive and sexual health services, including sexual health information, increases the vulnerability of adolescents in particular [Machel, 1996; UK Consortium on AIDS & International Development, 2002]. 2.1.3 Gender-based violence Gender-based violence is well documented in armed conflicts, and females of all ages are particularly vulnerable to abuse, rape, and sexual exploitation or enslavement [UNFPA, 2002; Machel, 1996; Jewkes, 2007]. The power imbalances that heighten women?s and girls? sexual vulnerability and enhance their disproportionate risk for HIV/AIDS become even more pronounced during conflict and displacement [Westerhaus, 2007; Ward & Marsh, 2006]. The heightened vulnerability to HIV of those surviving displacement camp living stems primarily from their elevated risk of both rape and sexual violence. HIV risk increases if there are multiple perpetrators or if women are held in captivity for long periods [Salama et al., 1999]. Violent sex greatly increases the risk of contracting the HIV virus from an infected partner [WHO, 2004; Zablotska et al., 2009] because genital injury disrupts the multi-layered stratified epithelium that lines a woman?s reproductive tract and acts as a natural barrier to infection [Foss et al., 2009]. Sexual violence can also have indirect effects on women?s vulnerability to HIV infection, as the depression, stigma and discrimination that often follow rape can lead to further cycles of exploitation or to high-risk activities such as drug use or sex work [UNAIDS, 2001; Swiss & Giller, 1993; Anema et al., 2008]. In the context of an emerging HIV epidemic, widespread sexual violence can have devastating health effects.   38 Although sexual violence is one of the gravest affronts to the health and dignity of women and girls in conflict areas, its full scale remains unknown. In part, this lack of knowledge and understanding may be attributed to the complexity of sexual violence itself and its intricate link to poverty, power, gender roles, displacement and all the other factors impacting on conflict-affected populations? livelihoods [UK Consortium on AIDS & International Development, 2002]. However, it may also be due to the serious under-reporting of cases of sexual violence due to the negative consequences that are often associated with disclosure including: stigmatization; ostracism; emotional disturbance, and; potential recrimination [Swiss & Giller, 1993]. Furthermore, Hanson et al. [2008] elaborate that the data that does exist may be anecdotal and biased in both collection and analysis. It is important to note that there exists some controversy regarding whether exposure to sexual violence or abuse in times of conflict does in fact increase the risk of HIV or other STIs. In a review of the literature investigating the relationship between violence and rape and the HIV epidemic in the Sub-Saharan region, Spiegel et al. [2007] concluded that there existed no data to support the premise that conflict affects HIV transmission. This finding was also reported by Anema et al. [2008], who concluded that widespread incidence of rape did not directly increase prevalence of HIV infection at the population level. In response, Jewkes [2007] has argued that these findings challenge conventional wisdom; that the brutal rape and sexual violence experienced by girls, women and boys, do in fact fuel the growing HIV epidemic in the Sub-Saharan region. Debate about the extent to which HIV risk is likely to be affected by rape and coercion in conflict/post-conflict settings should not confuse population-level and individual-level effects. In non-conflict, high and low conflict and post-conflict settings, an experience of rape may result in a large increase in an individual?s HIV  39 risk not only due to the potential effect of genital trauma, but also from the compounded risk associated with having additional partners and/or partners that are at high risk of HIV [Foss et al., 2009].  It is commonly reported that in conflict settings, the main perpetrators of sexual and gender-based violence (including rape) are regular military forces and/or rebel forces, consequently increasing displaced women and girls chances of contracting HIV [SMEC, 2005; Wollants et al., 1995; McCarthy et al., 1989; Plummer et al., 1991; Moses et al., 1991]. Rape, whether by ?homeland? or foreign soldiers, may be used to systematically terrorize and displace populations [Twagiramariya & Turshen, 1998; Crossette, 1998]. Widespread rape by combatants has been documented in Burundi [Amnesty International, 2004], Sierra Leone [Amowitz et al., 2002], Rwanda [Donovan, 2002], Democratic Republic of Congo [Amnesty International, 2004], Liberia [Swiss et al., 1998], Sudan [Amnesty International, 2004] and Uganda [UNICEF, 2005]. In peacetime, military personnel globally tend to have two to five times higher rates of STIs than the civilian population, and in conflict situations this difference can skyrocket to fifty times higher or more [UNAIDS, 2000]. These high rates of STI prevalence may be because combatants in the context of migration and mobility engage in unprotected sex with multiple partners, including sex workers [William Berg, 1984]. Soldiers and other men separated from their regular partners are more likely to frequent sex workers during war or migration [Wollants et al., 1995; McCarthy et al., 1989]. Large-scale prostitution creates core groups for epidemic spread of HIV and other STIs during conflict [Plummer et al., 1991; Moses et al., 1991]. In addition, William Berg [1984] notes that lack of adequate social programmes and recreational facilities for soldiers can lead to boredom, apathy and frustration, which may favor types of sexual expression that facilitate HIV and  40 STI transmission. Furthermore, the lack of adequate HIV/AIDS information and services provided to soldiers in times of conflict may also be a major factor in the spread of HIV and STIs [Hankins et al., 2002; SMEC, 2005].  A study by Spittal et al. [2008] pointed out that in times of conflict, sexual and gender-based violence - including the rape of women and adolescents - does not necessarily result only from interactions with soldiers, or rebels involved in abduction. It is also a result of living in the harsh physical conditions of forced displacement camps. Living in absolute poverty in over-crowded camps devoid of any means of livelihood makes young girls in particular vulnerable to exploitation and sexual violence by male camp residents and relatives, market traders, farmers, and businessmen, as well as members of armed forces [Hanson et al., 2008; Francis & McKibben, 2008; Spittal et al., 2008]. Indeed, in a review of gender-based violence in IDP camps in Sierra Leone during a decade-long conflict in the region, John-Langba [2009] reported that the main perpetrators of sexual violence, including rape, were men in uniform (army and rebels) and rowdy, drunken youth, as well as adult camp residents who consumed large amounts of alcohol. Furthermore, in Rwandan IDP camps, married women reported frequent physical domestic violence [SMEC, 2005]. In most cases, this gender-based violence was attributed to the inability of men/husbands to provide for their families and their consequent feelings of frustration. Amaro [1995] points out that power imbalances in relationships affect women?s ability to negotiate safe sex with their partners, subsequently enhancing their risk of contracting HIV and other STIs. Moreover, it has been postulated that after experiencing domestic violence, many women simply leave and find other partners, with whom they inevitably have unprotected sex, thus increasing their risk of contracting HIV [SMEC, 2005; WCRWC, 2001; Jewkes, 2007].   41 It is important to note that although women and girls experience unacceptably high levels of sexual violence related to war and displacement, there are many anecdotal accounts that suggest that during high intensity conflicts boys and men are as susceptible to sexual violence as women [USAID, 2000]. Closed environments, such as IDP camps or rebels? barracks, are potentially conducive to male/male rape or other non-consensual sexual penetration [Hankins et al., 2002]. Unprotected anal intercourse is a more effective means of HIV transmission than most other forms of sexual activity [Baggaley et al., 2010; Grulich & Zablotska, 2010]. The lining of the rectum has fewer cells than that of the vagina, and therefore can be damaged more easily, causing bleeding during intercourse and thus providing a direct route into the bloodstream for infected sexual fluids or blood [Baggaley et al., 2010; Grulich & Zablotska, 2010]. In a systematic review of the literature addressing HIV transmission risk through anal intercourse, Baggaley et al. [2010] report a summary estimate of probability of transmission by receptive anal intercourse of 1.4%, approximately 18 times higher than the estimated probability of male to female vaginal intercourse [Boily et al., 2009]. In northern Uganda it has been reported that a significant percentage of boys and men are also victims of sexual violence [Roberts et al., 2008; Sebunya, 1996; Uganda Child Rights NGO Network, 2004; World Vision, 2007]. There is an obvious need to better understand the impact of conflict on men?s susceptibility to sexual violence, as far less is known about it; the majority of research on sexual violence and HIV infection in times of conflict focuses on women and girls. 2.1.4 Summary A review of the applicable literature suggests that what we do know is that the direct and indirect effects of war and displacement have a profound impact on the HIV risk profile of  42 young people. The chaotic and brutal circumstances of war aggravate all the factors that fuel the HIV/AIDS crisis among this highly vulnerable group [Machel, 2001]. Young people are indeed caught in a web of vulnerability created by the social disarray of war.  2.2 After-Effects of War on HIV Epidemics and Young People Despite the very large number of conflicts that have occurred over the course of the last fifty years and increasingly significant investments in humanitarian relief that have transpired, important lessons remain to be learned about the period that follows cessation of hostilities and its implications for people. To date, donors and other key facilitators, including national authorities, have focused primarily on the physical aspects of reconstruction in the post-conflict period. By contrast, little concern has been shown for the social and human aspects of transition to recovery and reconstruction and, as a result, sustained social recovery has often been difficult to achieve [Carballo, 2009]. Nowhere has the neglect of social aspects of post-conflict contexts been more evident than in the case of HIV, where a global disease that has been instrumental in opening doors to new pandemics of TB and other devastating opportunistic infections has been overlooked in terms of both its social and biologic consequences and in opportunities for action. For example, in post-conflict Liberia, where there is a good mix of both international and local NGOs, the emphasis to date has been more on facilitating or encouraging a return of people from refugee and IDP situations. The work that has been done on HIV is severely limited and has been in the context of training local staff for maternal and child health work. Little action has been taken with respect to providing information and education on prevention, setting up VCT activities, or promoting follow-up of ex-combatants in regards to HIV, all actions that  43 could reduce HIV risk and curb the potential post-conflict spread of HIV infection [Carballo, 2009; Hankins et al., 2002].  The post-conflict process, taken to mean the transition from conflict to a period of stability, recovery and reconstruction, emerges as one that is not very well understood. Moreover, the literature base that elucidates post-conflict period risk factors for HIV/AIDS transmission remains inadequate. Hankins et al. [2002] state that HIV transmission dynamics after armed conflicts end are specific to local contexts. The speed of subsequent spread depends on HIV/STI prevalence at the baseline level, its distribution in the population, and the extensiveness in areas of return of habits of having multiple sexual partners [Morris, 1997]. The traumatic effects of wartime physical violence, sexual violence, and socioeconomic disruption shape these factors in turn. D?Awol [2008] similarly explains that the agents of the epidemic are rooted in the characteristics of post-conflict settings themselves, and often the social dynamics, economic constraints, trauma, culture and traditions, and developmental issues generate conditions that drive the behaviour of people, creating numerous risk factors for HIV exposure. For example, in Southern Sudan since the signing of the Comprehensive Peace Agreement in 2005, nearly two million IDPs and refugees have returned home [D?Awol, 2008]. Similar to post-conflict transition conditions in northern Uganda discussed previously, returnees are coming home to miserable conditions, most returning from areas with better services and security. Many are suffering from grave illnesses, hunger and malnutrition, subsequently enhancing their risk for HIV. In addition, the vast majority of the women and girls are illiterate and almost entirely disempowered. However, they continue to be forced to fend for themselves without  44 education and skills and are increasingly vulnerable to HIV due to the breakdown of social and family structures [D?Awol, 2008].   Periods of post-conflict transition are reported to be as difficult as living through as periods of active war [Machel, 2001; Becker et al., 2008]. Returning home presents new stresses such as land disputes and unexploded ordnance in return sites, lack of amenities and access to clean water, and absence of institutional infrastructure. This is all compounded by the diminishing presence of NGOs offering emergency assistance, as relative peace prevails in the region. In addition, the impact of years of violence on the mental health of survivors begins to emerge post-conflict.  Recent attention has been given to the role of Post-Traumatic Stress Disorder (PTSD) and other trauma-related disorders in the context of HIV. Extant literature suggests that PTSD can enhance HIV-related vulnerability in three ways: First, individuals with a PTSD diagnosis are more likely to engage in higher risk sexual behaviour, such as not using condoms and having numerous sexual partners, which may increase their risk of infection [Brief et al., 2004; Gore-Felton & Koopman, 2008; Meade & Sikkema, 2007; Rosenberg et al., 2001]. Second, exposure to trauma and PTSD has been found to have a negative impact on immune function among individuals with HIV [Leserman, 2008; Leserman et al., 2007]. Finally, a PTSD diagnosis has been found to interfere with adherence to medications by individuals with HIV/AIDS, resulting in more rapid progress of the disease [Cohen et al., 2001; Mugavero et al., 2006; Whetton et al., 2008].  In a recent study, Roberts et al. [2008] reported that 54% of adults living in IDP camps in northern Uganda met symptom criteria for PTSD, with women significantly more likely than men to develop the disorder (60% vs. 46%, respectively). The authors suggest that the  45 levels of PTSD and depression are amongst the highest recorded globally using similar methodologies. Furthermore, there is additional evidence suggesting that young people who have been abducted by the LRA are at especially high risk of trauma. Ovuga et al. [2008] reported that 55.9% of their study sample of children who had returned from the bush in the Sudan suffered from symptoms of PTSD. In a further study by Ovuga & Larroque [2012] it was reported that many young people, abductees and non-abductees, residing in Gulu District experienced significant levels of not only PTSD but also other mental health problems including anxiety disorders, depression and suicidal behaviour, all trauma-related health concerns that can enhance HIV-related vulnerability. In addition, young people who have survived war and displacement may have only experienced a life of dependency and desperation, allowing them to accept and engage in behaviours that were not tolerable to previous generations, also subsequently enhancing their risk of contracting HIV. In Angola for example, it was observed that following the end of the civil war in 2002, alcoholism and drug use increased considerably among young people, and this consequently supported increased incidents of sexual abuse and normalized violence in communities [De Jong, 2003]. Furthermore, these young people may be unmotivated to establish livelihoods and begin to re-build their lives due to loss or diminishment of livelihood skills during prolonged displacement, resulting in high rates of poverty and unemployment during post-conflict periods [Machel, 2001; Wessells & Edgerton, 2008]. Living in a traumatized state, impoverished, unemployed, and socially dislocated from many years of entrenched warfare, this disconnected and disaffected demographic is particularly at risk of contracting HIV/AIDS during the post-conflict process [Machel, 2001].   46 Although it would be wrong to assume that people in the midst of conflict and people emerging from conflict are more or less alike, certain factors increasing the HIV vulnerability of people during conflict do persist well after the conflict is over because of fundamental social changes that occur over time [Mock et al., 2004; UNHCR, 2006]. For example, some would suggest that heightened sexual violence against women and girls becomes normalized during protracted conflict and continues well into the post-conflict period as IDPs cope with instability and return to new challenges in their villages of origin [Ward & Marsh, 2006; Lowicki-Zucca et al., 2008; Mock et al., 2004; Jewkes, 2007]. John-Langba [2009] reported that during the conflict in Sierra Leone, the marginalization of victims of sexual violence, the lax attitude adopted in the face of such serious crimes, and the failure to investigate, prosecute and punish those responsible for rape and other forms of gender-based violence has made it difficult to change attitudes and practices towards sexual violence and exploitation now that the war is over. In fact, these failures have contributed to an environment of impunity in post-conflict Sierra Leone that perpetuates violence against women and girls (including rape and domestic violence) of which family members, elderly wealthy men, teachers and lecturers are the main perpetrators. There is general consensus that women and girls are among the most vulnerable in times of conflict as well as after the cessation of hostilities [UN, 2001; Westerhaus et al., 2008; D?Awol, 2008]. Carballo [2009] asserted that in post-conflict DRC, Haiti and Liberia, it is displaced women and girls who are in need of the most protection as an increase in frequency of sexual abuse and exploitation has been observed in all three countries since their respective cessations of hostilities. Similarly, Benjamin [2001] concluded that women and  47 girls in post-conflict Sierra Leone are particularly vulnerable to HIV and AIDS, as they are deliberately targeted for rape, trafficking, sex work and forced marriages. 2.2.1 Summary The general reluctance to describe and characterize the period that follows peace accords and ceasefires in terms of how it affects different segments of the population has its roots in a willingness to see the people involved as a relatively homogenous group devoid of any distinctive needs or capacities [Carballo, 2009]. Therefore, very few, if any, models exist of how people involved in post-conflict transition should be assessed, and responded to. To the knowledge of this study?s researchers, there is currently no established set of best practices to guide policy and programming for addressing HIV/AIDS in post-conflict countries. While conflicts inevitably bring out resilience and personal strengths in many people, they also exacerbate any vulnerabilities that existed prior to conflict and displacement and create new ones as well, and they do so in ways that can continue to dominate the lives and capacities of people even long after conflicts have come to an end [Mock et al., 2004; UNHCR, 2006]. Assumptions that people going into, and emerging from, conflicts are more or less alike have failed to acknowledge this variability. The cessation of complex emergencies and the initiation of development and rebuilding processes allow steps to be taken to reduce HIV transmission, provide support to those already infected, and mobilize a sustained response against conditions leading to further spread [Hanson et al., 2008]. With a protracted post-conflict period currently occurring in northern Uganda, it is critically important to provide an accurate understanding of the magnitude and determinants of HIV infection among young people surviving war and displacement, to inform effective post-conflict HIV prevention and care programming.    48 2.3 Risk Factors for HIV Infection Among Conflict-Affected Populations in Northern Uganda  In northern Uganda, there are numerous non-government organizations (NGOs) that have expressed grave concern over the paucity of evidence regarding the progress of the epidemic and the extent to which war-related factors may have heightened HIV-related vulnerability, particularly for those who have survived displacement camp circumstances [Westerhaus et al., 2008]. While the abduction of children, early marriage and defilement, and sex-for-exchange relationships with both armed forces and fellow camp residents have been considered the stark daily reality for thousands of displaced people for years, the link between these factors and prevalence rates of HIV has never been established [Westerhaus et al., 2008; Spittal et al., 2008]. In addition, as northern Uganda transitions into resettlement and repatriation processes, District officials are concerned that the causal factors of the epidemic could change quite rapidly [P. Odong, personal communication, May 5, 2009; M. Ogwang, personal communication, May 12, 2009]. Since the signing of the cessation of hostilities agreement in 2006, there is now in existence: a strong trade corridor that has been established to transport agricultural products and cattle to the Southern Sudan; increased mobility as people transition out of primary camp settings to either transit camps or back to their traditional homesteads, and; some very troubling evidence to suggest that young Acholi women who grew up in camp settings and never learned agricultural skills are transitioning directly into sex work along the new corridor [IOM, 2008]. Responding to the dearth of information in the new post-conflict reality in the North will greatly improve evidence-based HIV programming. What follows is a review of this study?s analyses of the main risk factors for HIV infection in northern Uganda.  49 2.3.1 History of IDP camp living The more than two-decades-long conflict in northern Uganda resulted in the displacement of nearly two million people, which accounted for over 90 percent of the population in the region [Republic of Uganda & WHO, 2005; Westerhaus, 2007; Mazurana & McKay, 2004; Fabiani et al., 2007a]. Numerous reports on the conditions of IDP camp living in northern Uganda illustrated high levels of gender-based violence, survival and transactional sex, maternal malnutrition, over-crowding, and a lack of preventative health services available within the camps [Republic of Uganda & WHO, 2005; Dolan, 2009; Oxfam, 2008; Spittal et al., 2008; UNHCR, 2007; WCRWC, 2005; SMEC, 2005]; these are all factors shown to drive HIV transmission risk in conflict settings [Spiegel et al., 2007; Mills et al., 2006; Hankins et al., 2002]. Given these HIV risk factors associated with IDP camp living, in addition to the possible protective effect on HIV infection of persons remaining isolated and unable to access urban centres for years, it will be interesting to analyze the relationship between the structural factor of duration of encampment and risk of HIV infection. 2.3.2 Child abduction Child abduction by the LRA has had a profound impact on the physical and psychosocial wellbeing of young people in northern Uganda. Estimates of numbers of children abducted range from 30,000 to 66,000 over the course of the conflict, most of them being between 6 and 13 years old [Nannyonjo, 2004; Annan et al., 2006; SWAY, 2008]. More boys than girls were abducted. Both academic literature and NGO reports describe scenarios in which abducted young boys were indoctrinated into a culture of violence whereby violence and threats were used to coerce them into using torture, killing, and rape as weapons of war,  50 placing themselves as well as their victims at increased risk of contracting HIV and other STIs [Westerhaus et al., 2007; Fabiani et al., 2007a; Annan et al., 2006; De Temmerman, 2001; IRIN, 2007; Westerhaus et al., 2008; Patrick, 2005]. While conflict literature focuses mainly on male abductees as active fighters in the majority of armed conflicts, abducted females are also made to fight [McKay, 2005; McKay & Mazurana, 2004]. The iconic image in war is a young man with an AK-47 while young women are typically depicted as victims who are mourning dead male family members, fleeing and searching for food, struggling to care for a child, or experiencing sexual abuse [Cohen, 2009; Coulter, 2008; Onyango et al., 2005; Ross, 2003; Theidon, 2007]. This relegation to the status of vulnerable victims drives policy-making at the global level, donor funding at the national level, and programme design on the ground [Annan et al., 2009; Blattman & Annan, 2008]. As Annan et al. [2009] point out, women and girls who were abducted were neither passive victims nor regular fighters, but something in between. They were sexually abused, but almost exclusively within the confines of a forced ?marriage? to a rebel commander, and rape outside of these forced marriages was rare. It is also believed that the rebels were reluctant to abduct older girls out of a fear that they might already be infected with HIV/AIDS. Instead, girls of premenstrual age were targeted precisely for this reason [Spittal et al., 2008; Allen, 2006a; Annan et al., 2009; Beber & Blattman, 2009]. While there is much speculation that female abductees were heavily impacted by HIV infection while living in the bush, there is no evidence to support that people with a history of abduction are more likely to be HIV-positive than non-abductees surviving displacement camp circumstances [Annan et al., 2009; Allen, 2006a]. Therefore, it is critical to examine the reproductive health needs and the HIV-related vulnerabilities of young people with a history of abduction as well as non-combatants.  51 2.3.3 Night commuting An additional Operation Iron Fist (OIF) related phenomenon, known as night commuting, placed thousands of children and adolescents at risk for HIV and other STI infections [Westerhaus et al., 2007; Westerhaus et al., 2008; Amnesty International, 2005; IRIN, 2003; Li, 2005]. In response to the insecurity of their rural communities, an estimated 40,000 ?night commuters? traveled to the nearest town each evening, unaccompanied and unsupervised by adults, seeking protection from abduction by the LRA. They would sleep in churches and hospitals, on verandas and in shelters erected by the NGO community in town (some slept 250 to a shed) [Falk et al., 2004; WCRWC, 2004]. Spittal et al. [2008] uncovered another night-commuting phenomenon in northern Uganda; as a result of fear of abduction and cultural considerations pertaining to privacy, children moved from their family hut at night from the outskirts of camps to seek shelter in more central locations within their camp?s perimeters. Unfortunately, the hundreds of children moving within the perimeters of the camps has not been highly recognized as a night-commuting phenomenon in and of itself, and has therefore not been properly assessed with a view to acquiring data on HIV or from a policy perspective. Yet a number of reports have highlighted the concerns about the heightened vulnerability to HIV among young women and girls who night-commuted not only to town but also within their camp?s perimeters. Girls were often waylaid and raped en route or while in ?safe? places by local youth and drunken men in Gulu town, or IDP youth or soldiers in the camps [Save the Children Uganda, 2004; SMEC, 2005; Spittal et al., 2008]. 2.3.4 Early and coerced sexual debut Prior to the conflict in northern Uganda, Acholi girls traditionally experienced significantly high levels of personal and sexual security before menstruation and marriage  52 [Ominde, 1952; Patel et al., 2011; Spittal et al., 2008]. Age of sexual debut was anywhere between the ages of 14 and 18 and could only occur after the adolescent had regular menstrual cycles. The highly structured roles played by female relatives, belief systems, incest taboos and the bride wealth system guarded against premature sex and the sexual violation of girls [Spittal et al., 2008]. In northern Uganda, NGOs have reported concerns over the high prevalence of early sexual debut, which has been identified as a significant risk factor for HIV infection in other Sub-Saharan populations [WCRWC & United Nations Population Fund, 2007; Akumu et al., 2005; Mugisha, 2006; Uganda Law Reform Commission, 2006; UNHCR, 2006; Gottschalk, 2007; Hallett et al., 2007]. For example, in Zimbabwe, Pettifor et al. [2004] demonstrated that women who reported early coital debut at less than 15 years of age had a higher risk profile (i.e., multiple partners, transactional sex) and were significantly more likely to be HIV-positive. As a result of increased exposure opportunity and the physiological and immunological immaturity of the female genital tract, early sexual debut is identified as a significant risk factor for both HIV and other STIs [Hallett et. al., 2007; Glynn et. al., 2001; Drain et. al., 2004; Kaestle et. al., 2005].  However, it has been argued that age of sexual debut alone is not directly related to HIV and other STI infections, but rather it is the type of experience at sexual debut that is a better predictor of infection. Specifically, emerging evidence suggests that coerced sexual debut, defined by Heise, Moore, and Toubia [1995] as ?violence, threats, verbal insistence, deception, cultural expectations or economic circumstances" that result in the "lack of choice to pursue other options without severe social or physical consequences" places young girls at increased risk of HIV and other STI infections [Harrison, 2005; Maharaj & Munthree, 2007; Sa & Larsen, 2006; UNAIDS, 2004]. Koenig et al. [2004] reported that of 575 sexually  53 experienced girls aged 15 to 19 years from Rakai, Uganda, the risk of coercive sex increased with younger age of sexual debut and that girls who reported being forced during their first sexual experience were significantly more likely to report one or more symptoms of genital tract infection. The study also found that after controlling for other risk factors, coercive first sex was associated with a 71-percent higher risk of subsequent HIV acquisition [Koenig et al., 2004]. A high prevalence of non-consensual first-time sex, defilement (i.e., a sex crime against minors that seems to thrive in widespread poverty), and early forced marriage in northern Uganda, has been well documented through NGO reporting and human rights forums [WCRWC & United Nations Population Fund, 2007; SMEC, 2005; Westerhaus et al., 2007; Westerhaus et al., 2008; Annan et al., 2006; Patrick, 2005; IRIN, 2007]. However, despite growing recognition of the issue, there is little evidence of the relationship between coerced sexual debut and HIV in both northern Uganda and the rest of Sub-Saharan Africa [Zablotska et al., 2009].  2.3.5 Traditional practice of dry sex In northern Uganda the use of substances to reduce vaginal secretions in order to create a drier, tighter vagina for the purpose of increasing men?s sexual pleasure and the desire of women to establish fidelity has gone relatively undocumented. However, in the past two decades, it has become increasingly apparent in both the epidemiological and, to a lesser extent, the social science literature, that this research is of critical importance especially in areas heavily affected by HIV [Scorgie et al., 2009, Schwandt et al., 2006; Hyena, 1999]. Dry sex practices decrease the presence of vaginal secretions containing lactobacilli, the body?s natural defense to infection. Lack of lubrication during penetration increases the likelihood of lacerations in the vaginal wall, creating an environment susceptible to infection [Hyena,  54 1999]. Recent research in Kenya, South Africa and Mozambique has suggested that dry sex practices may directly contradict HIV prevention messages, including the use of lubricated condoms [Scorgie et al., 2009; Schwandt et al., 2006; Bagnol & Mariano, 2008; Mehta et al., 2007; Mehta et al., 2008]. These findings reinforce other literature that confirms the relationship between vaginal practices (including dry sex) and women?s susceptibility to both HIV infection and other STIs [Myer et al., 2005; Schwandt et al., 2006]. Furthermore, studies in Kisumu, Kenya, have demonstrated that young men who preferred dry sex were 1.5 times more likely to have a non-ulcerative STI [Mehta et al., 2007] and 1.4 times more likely to have acquired HSV2 at baseline [Mehta et al., 2008]. In a study by Spittal et al. [2008] conducted in IDP camps in northern Uganda, both adolescent girls and men acknowledged the cultural and sexual importance of dry sex practice in Acholiland. However, no epidemiological evidence related to practicing or preferring dry sex exists. It is important to establish the prevalence and scope of the practice (cleansing, use of herbs, cutting) in order to determine its relationship to HIV prevalence, and to inform appropriate prevention programming, if a relationship does exist. 2.3.6 Food security During encampment in northern Uganda, camp residents were completely dependent upon food aid provided by the United Nations World Food Programme. Unfortunately, this food supply was insufficient to meet basic daily nutritional requirements, and delivery, dependent on road security, was intermittent at best [SMEC, 2005]. There is a growing recognition by NGOs and the academic community that food insufficiency in times of conflict may enhance sex-related HIV vulnerabilities (i.e., subsistence sex, intergenerational sex, coerced sex) [Mock et al., 2004; Weiser et al., 2007; UNCHR, 2006; Spiegel, 2004].  55 Furthermore, there is mounting evidence in the Sub-Saharan region that this is a highly gendered phenomenon [Weiser et al., 2007; Oyefera, 2007]. Mock et al. [2004] have argued that transactional sex in conflict settings is used as a coping strategy by women and girls who often have little or no access to resources. Power dynamics come into play when women are food-dependent, enhancing the likelihood that condom use may not be negotiable. Weiser et al. [2007] demonstrated that in a sample of 1050 women from Botswana and Swaziland, food insufficiency (measured as not having enough food to eat over the previous 12 months) was associated with inconsistent condom use with a non-primary partner; sex in exchange for money, food, or other resources; intergenerational sexual relationships, and; lack of control in sexual relationships. These sex-related vulnerabilities have been significantly associated with increased risk for HIV and other STIs [Jewkes, 2001]. It is now generally accepted that those who are malnourished are more susceptible to HIV once exposure has occurred. The lack of food weakens the immune system and compromises the mucosal membranes of the genital tract [Gillespie & Kadiyala, 2005; De Waal & Whiteside, 2003]. Many NGOs and the academic community have observed that after the decades-long conflict in northern Uganda, aggravated by inadequate support from the international community, women and girls have been forced to engage in transactional sex to feed their families and to provide educational opportunities for their children [SMEC, 2005; WCRWC, 2005; Oxfam, 2008; Westerhaus et al., 2008; Spittal et al., 2008; Patel et al., 2011]. However, Bukuluki et al. [2008] suggested that for Gulu and Amuru Districts, NGO reports and academic publications are largely silent on the interactions between sexual exploitation, perennial lack of food, and HIV/AIDS in the context of conflict. This paucity of data has led to generic policies and interventions on HIV/AIDS and food and nutrition security for all  56 categories of IDPs, without targeting the specific vulnerabilities and unique needs of girls and women in armed conflict situations. This dearth of information addressing food insecurity and its implications for the HIV crisis in Gulu must be addressed [Bukuluki et al., 2008; ICRW, 2003]. Moreover, by March 2009 the United Nations WFP had completely shut down all services and withdrawn support from the majority of IDP camps, including school feeding programmes and supplemental feeding centres. Coupled with recent drought and crop failure in the region, the Ugandan media has suggested that the high incidence of hunger experienced by villagers moving back home during the post-conflict process is actually much worse than at the height of insurgency [IRIN, 2009a; IRIN, 2009b; IRIN, 2009c; IRIN, 2009d; IRIN, 2009e]. 2.3.7 Mobility Mobility of a population, generally involving mass numbers of individuals moving from rural areas to urban areas for protection during conflict or for economic opportunities post-conflict, has been identified as a risk factor for HIV infection [Buve et al., 2002; Mock et al., 2004; UNAIDS, 2001]. After conflict ends or subsides, avenues of transportation open, allowing populations to move freely from rural centres with traditionally low infection rates to urban centres with higher HIV prevalence rates [Hanson et al., 2008]. With prevailing peace in northern Uganda, IDMC reported that by December 2010, 90% of former IDPs had moved to back to their ancestral homes while the remaining 10% were living in transit sites/camps [IDMC, 2010]. Among this population of returnees, a high degree of mobility has been observed as people move between former IDP camps, transit sites, and villages to cultivate land, and/or access basic services and education that are not yet available in home villages/return sites [Oxfam, 2008]. In addition, as a consequence of the signing of Sudan?s  57 Comprehensive Peace Agreement in 2005, and the Juba Peace Process between the GoU and the LRA in 2006, the acrimonious relationship between North and South Sudan was partially resolved and, as a result, trade between the South Sudan and northern Uganda is booming [IOM, 2008]. In such regions emerging from periods of violent conflict, cross-border trade offers opportunities for re-establishing contacts and relationships, and for building new links between communities estranged by violence. A consequence of this new post-war economy involves cross-border movement of truckers, agricultural traders, and cattle-loaders, all core groups heavily impacted in the early phases of the HIV epidemic in the South-West region of Uganda [Kirunga & Ntozi, 1997]. Unfortunately, increased incidence of transactional and subsistence sex has been reported all along the Kampala Juba highway, including in Gulu District [IOM, 2008]. While sex work was definitely part of life before the war, it is now a source of growing discussion, disquiet and even tension within some communities because of its relationship to HIV infection [P. Odong, personal communication, May 5, 2009].  2.3.8 Alcohol use  Concern has been raised about alcohol abuse among displaced populations, including IDPs, and the development of substance-related harms, such as HIV infection [Johnson, 1996; UNHCR & WHO, 2008; Strathdee et al., 2006; Friedman et al., 2009]. During hostilities, IDPs may be exposed to a large number of traumatic and violent events and may subsequently experience post-traumatic stress disorder [Porter & Haslam, 2005; Steel et al., 2009], which may be a risk factor for alcohol disorder [Stewart, 1996]. Alcohol use may also be a coping mechanism for other commonly experienced stressors of encampment such as poor living conditions; poverty; lack of livelihood; idleness; the loss of self-esteem; the erosion of cultural and social supports, and; high rates of depression, anxiety and generalized  58 psychological distress [Ezard et al., 2011; Weaver & Roberts, 2010; de Jong et al., 2003].   Previous studies in Sub-Saharan Africa have demonstrated that alcohol use may be a risk factor for HIV because it impairs judgment, disinhibits sexual risk-taking and is associated with unprotected sex [Kalichman et al., 2007; Zablotska et al., 2006]. For example, in Rakai District, in the south-western part of Uganda, Zablotska et al. [2006] found a significantly higher risk of HIV among men and women who reported alcohol use before sex, and cited behavioural disinhibition and sexual risk-taking under the influence of alcohol as possible explanatory mechanisms. There has been some reporting on the high levels of alcohol consumption amongst the conflict-affected population in northern Uganda [Gulu District Sub Working Group On Sexual and Gender Based Violence, 2005; SMEC, 2005; Huber, 2010; International Medical Corps, 2011; Roberts et al., 2011]. In a recent cross-sectional study with 1206 adult IDPs in Gulu and Amuru Districts, 80% of the sample reported drinking once a month or less while 17% of the sample were categorized as having alcohol disorder, measured using the AUDIT instrument [Roberts et al., 2011]. Although this study contributed epidemiological data on the levels of alcohol use among IDPs in northern Uganda, the evidence base on which to build interventions remains sparse. Moreover, research is needed for establishing and further understanding the relationship between alcohol use and risk of HIV infection. Post-conflict HIV prevention efforts would benefit from greater knowledge about the effect of high levels of alcohol consumption on the HIV epidemic. 2.3.9 Gender-based violence The heightened HIV vulnerability of women and children surviving displacement camp living in northern Uganda stems primarily from their elevated risk of both rape and sexual  59 violence. Exposure to sexual violence, including rape and defilement, has been well documented in the region through NGO reporting and human rights forums [SMEC, 2005; Westerhaus et al., 2007; Westerhaus et al., 2008; Annan et al., 2006; Patrick, 2005; IRIN, 2007]. There are numerous reports demonstrating alarming levels of sexual violence and mass rape by armed forces, including the LRA and the UPDF, when women and girls are collecting firewood or tending to their gardens on the outskirts of camps [Westerhaus et al., 2007; Patrick, 2005; SMEC, 2005; Patel et al., 2011]. Furthermore, the rape of unsupervised young girls and women within IDP camps by fellow camps residents was considered commonplace, as was marital rape [World Vision, 2004; Akumu et al., 2005]. Of note is that a significant percentage of boys and men in northern Uganda are also victims of sexual violence [Roberts et al., 2008; Sebunya, 1996; Uganda Child Rights NGO Network, 2004; World Vision, 2007]. For example, in a cross-sectional study examining factors associated with PTSD and depression among adult IDPs in northern Uganda, it was reported that 8% of men had been raped or sexually abused [Roberts et al., 2008]. There exists some controversy (discussed above) regarding whether exposure to sexual violence or abuse increases the risk of HIV or other STIs. This debate is a stark reminder of the need to better understand the mechanisms mediating the relationship between sexual violence and HIV. For example, it has been suggested that experiencing a traumatic event in childhood (for example, a non-consensual sexual debut) is correlated with an increased likelihood of engaging in risky sexual behaviour, thus increasing the risk of contracting HIV or other STIs [Lindegren et al., 1998; Johnson, 2004; Koenig et al., 2003; Stewart et al., 1996].     60 2.4 Summary of Literature Review The primary aim of this review was to provide an overview of the literature relevant to the forthcoming studies described in the current dissertation. The review provided a summary of the historical and emerging research literature on the relationship between conflict and post-conflict settings and HIV/AIDS among young people, while highlighting gaps in knowledge that this dissertation will address. First, the influence that structural, economic, social and behavioural factors associated with conflict settings have on HIV risk was described. Next, the limited literature analyzing the after-effects of war on HIV epidemics was presented. Finally, the review described potential risk factors for HIV infection specific to the conflict/post-conflict contexts of northern Uganda, which are analytically assessed in forthcoming studies in this dissertation. Chapters 4 through 6 will follow, each comprising an analysis based on the study objectives outlined in Chapter 1 and guided by the content of this literature review.            61 Chapter  3: Methodology The candidate ran and funded this study independent of any ties to a larger research study. She recruited, trained, supervised and managed a team of researchers, developed her own research tools and protocols, coordinated all study activities in the field, completed data entry and conducted all statistical analyses. This chapter describes study design; sampling methods; description of the research team; data collection instruments and protocols, and; data management and analysis. 3.1 Study Design This research employed a cross-sectional study design to determine prevalence and determinants of HIV infection among young people, aged 15 to 29 years, residing in transit sites in Gulu District, northern Uganda. This design was deemed necessary to address the overall objective of this research and highlight the patterns of risk of young people in post-conflict transition.  3.2 Sampling  3.2.1 Site selection  Fieldwork was conducted solely in Gulu District, which is comprised of 2 counties and 23 sub-counties and, as of 2010, had an estimated population of 374,700 [Ministry of Water and Environment, 2010]. Gulu District is named after its chief municipal, administrative and commercial centre, Gulu town, and is one of the seven Districts that constitute the Acholi sub-region, or Acholiland. Located 332 km from the national capital Kampala, Gulu District has traditionally been widely acknowledged as the capital of the northern region [Dolan, 2009]. We chose to carry out this study in Gulu District, as it was the most severely impacted District during the protracted war between the Government of Uganda and the LRA. There  62 had been heavy rebel incursions in the District owing to its strategic location as a corridor between Sudan and Murchison Falls National Park, locales where rebels would be based and could hide out. In 2005, the health and mortality survey of Internally Displaced Persons indicated that Gulu District housed the greatest number of displacement camps in the Acholi sub-region. There were reportedly 53 IDP camps in Gulu District alone where more than 80% of the entire population of the District was encamped [Republic of Uganda & WHO, 2005]. The total camp population estimate for the District was 257,000 [UN OCHA, 2008]. Population estimates from UN OCHA revealed that as of 2008, 60% of this total camp population were still living in IDP camps, 39% were living in transit sites, and 43% had returned home and were living permanently in their villages of origin [UN OCHA, 2008].  This study was initiated in Gulu District in May 2010, four years after the cessation of hostilities and three years after the population had been granted freedom of movement. When the study commenced, almost all of the IDP camps in the District had been officially closed and a large proportion of the encamped population had either moved back to their village of origin or to a transit camp/resettlement site [District Camp Phase-Out Committee, 2010]. According to UN OCHA [2010b], as of June 2010, 52 of 53 of the original IDP camps in the District had been decommissioned and officially closed, with only one camp remaining open. In line with the study objectives, our target population was young people 15 to 29 years old, living in a transit site, who had experienced conditions of conflict and displacement. Therefore, once in the field, we surveyed the situation and consulted the latest transit site assessment report for the District to determine our sampling locations [District Camp Phase-Out Committee, 2010]. Based on this report and the most recent Uganda Census [UBOS, 2002], we generated a list of all sub-counties in Gulu District that had transit sites (i.e., 18/23  63 sub-counties), and subdivided this list by the 2 counties in Gulu District (i.e., Aswa and Omoro counties). From this master list we randomly selected 2 sub-counties (one from each county) to be included in our study (Ongako and Awach), using a table of random numbers. The study population came from 12 transit camps located in either Ongako or Awach. The camps were selected purposively from the source population, with the guidance of key informants, to reflect a range of remoteness/accessibility and resource availability. Table 3.1 summarizes our site selection process. Table 3.1    Breakdown of site selection District  Gulu  County  Aswa  Omoro Sub-county  Awach  Ongako  Transit Camp Paibona Awach Paduny Alokolum Anaka Acut-Omer Kal-Centre Onyona Pida Loro Owak Peya Ogony  3.2.1.1 Ongako sub-county Ongako sub-county is located in Omoro County, approximately 10 km away from the urban centre of Gulu town. According to the most recent national census figures, the population of Ongako sub-county is estimated at 14,360 [UBOS, 2002]. As of July 2007, there were 45 water sources in the sub-county, of which 36 were working, as well as 2 functional health units. In addition, residents of Ongako were in close proximity to Lacor District Hospital, a fully functioning non-profit Ugandan hospital founded in 1959. During  64 the war, this is where many of the children in Ongako commuted to every night to avoid abduction. As of May 2008, there were 5 functioning primary schools in Ongako [UNHCR, 2008b]. While in the field in 2010, other community infrastructure was visible, including: a market with cement walls; numerous shops; grinding mills; drug dispensaries; police posts, and; non-governmental aid organization, community-based organization and government sub-county offices. Due to various barriers, however, not all residents had access to services. Food and water security in Ongako sub-county was generally normal, with a reported 74.27% of the population reporting food self-sufficiency from their crops, the highest in the District, and a reported 88% of the population having access to safe water (mostly in the form of spring wells and boreholes) [Obbo, 2009; Ministry of Water & Environment, 2010]. The return of residents to their home villages appeared to have three phases: pre-transition, early transition, and late transition, with more residents observed to be in the latter two phases when compared to Awach sub-county. In most cases, people had moved out of the camps and built similar living places (round huts made of brick and grass thatched roofs) in an area nearer their home location, in a cluster set-up. In these new transit sites, IDPs may repossess original land and begin building a base, while still enjoying services, markets, security and social lives. Although this communal set-up did provide more security, residents still complained about insecurity related to property theft. While there was a visible police presence in Ongako, it was associated with general feelings of mistrust and insecurity; it was commonly reported that police bribes, usually in the form of money, needed to be fulfilled first in order to receive police services. The locations of the nine transit camps/sites from which we sampled in Ongako were spread out across the sub-county. However, access to  65 participants was relatively easy, with minimal driving and walking required of the researchers. 3.2.1.2 Awach sub-county Awach sub-county is located 45 km north of Gulu town (approximately a one-hour car ride) and is comprised of 4 parishes and 13 villages. Compared to Ongako sub-county, Awach may be considered remote. As of 2008, Awach was home to an estimated population of over 10,000 [Lanekatuk Memorial, Inc., 2010]. In late 2010, Gulu University set up a Demographic Surveillance System site in Awach to trace the post-conflict resettlement process in detail. Preliminary data demonstrated that more than 50% of the population of Awach was comprised of young people under the age of 20 years, which presents its own sets of strategic needs, challenges and opportunities with respect to improving human security in a post-conflict situation [Law, 2010]. This large proportion of young people in Awach was immediately visible to us upon our first visit to the sub-county to seek permission and introduce the research team and our study to sub-county and local council officials and camp leaders.  As in Ongako county, the return of residents to their home villages appeared to have roughly three phases: pre-transition, early transition, and late transition. Although the exact proportion of the population in Awach who were residing in transit camps at the time of data collection was unknown, our own observations led us to conclude that Awach had relatively more residents in the pre-transition and early transition phases, when compared to Ongako sub-county. However, as noted in a report by UN OCHA [2007], the number of people remaining in IDP camps and transit camps should not be understood as a measure of a county?s progress with the returns process. A more accurate measure is the proximity of  66 people?s pre-displacement ancestral land to the current displaced location (i.e., IDP or transit camp); distance to their own agricultural land is a significant factor in the decision-making process regarding whether to leave the camps. A large percentage of the population may opt to reside in the camps long-term while accessing their pre-displacement ancestral land by commuting. Seen in this way, a measure of returns does not necessarily have to include permanent physical movement from IDP camps back to pre-displacement villages. Ninety-two percent of the households in Awach sub-county are within 5 km (50 minutes? walk) of their pre-displacement homes, compared to 53% of households in Ongako sub-county [UN OCHA, 2007]. As of 2008, household access to land ranged between an average of 8-15 acres with only 2-4 acres of this available land utilized for agricultural activities in the last planting season [Obbo, 2009]. However, food security in Awach sub-county was generally normal, with a reported 62.09% of the population reporting food self-sufficiency; this is second highest in the District after Ongako sub-county [Obbo, 2009].  The three transit camps from which we sampled in Awach were located approximately 30 to 45 minutes away by car from Awach centre. These camps can be considered rural sites that were difficult to access, particularly after heavy rains, due mainly to the roads being badly rutted with potholes filled with mud and water. Road conditions would necessitate our research assistants leaving the car when it was impossible to drive further and then walking to reach the transit camps they were sampling from. Due to the remoteness of this sub-county in general, our study team initially suggested that they would set up camp in Awach on a weekly basis, eliminating the chance of not being able to reach our sampling locations in the event of heavy rains. However, the candidate was uncomfortable about the security of her  67 team on an overnight stay in Awach, so they continued traveling to Awach daily, weather permitting.  It was apparent that sites away from Awach centre were remote and under-resourced, with most residents facing limited access to healthcare, water points and education. Community infrastructure in Awach was relatively sparse. The team saw no markets except for a few groups of local women sitting on the ground with their wares (usually vegetables) laid out in front of them. One of the transit camps we sampled from was called Paduny camp, which was located in Paduny parish. This parish was host to one of the only functional health centres (HC IV) in the sub-county. Medical personnel there lamented that their delivery of health services is severely challenged by inadequate staff, inadequate medical equipment and frequent shortages of drugs and supplies. They did have staff trained in HIV counseling and testing but no availability of mental health or psychosocial support. The frequent stock-outs were attributed to the cessation of NGO efforts after the northern region was no longer considered to be in a state of ?emergency?. The impact of this shift in humanitarian support was starkly illustrated by a new health centre built by MSF adjacent to Paibona camp in 2009, which during our time in the field in 2010 remained completely empty without any health personnel or supplies. The absence of clean and safe drinking water was also apparent, with the majority of the protected water sources located in former IDP camps. This has resulted in a large proportion of transit camp residents continuing to access basic services such as clean water from main IDP camps, when possible. Paduny parish had no secure water source in any of the camps [Ministry of Water & Environment, 2010]. Available latrines are also concentrated in the IDP camps, leaving inhabitants of transit camps primarily using bushes for defecation. There are also very few fully established and adequately resourced  68 schools in return area sites in the sub-county, resulting in children being left behind to access better schooling facilities in IDP camps without parental care [UN OCHA, 2008].  3.2.2 Participant selection We had initially planned to use the Stratified Systematic Random Sampling method to generate a representative sample of individuals aged 15 to 29 residing in a transit site located in one of two randomly selected sub-counties in Gulu District, with an even number of males and females. However, when we met with sub-county officials during our community preparation phase, it became apparent that local council registries listing all current transit site residents in the area either did not exist or were outdated or incomplete.  The mobility of the population, coupled with sustainability issues of returns, made documenting a comprehensive and accurate census of residents living in transit camps fairly impossible for District officials. As these local council registries were intended to make up our sampling frame, we were forced to revise our methods.  It was evident that attaining a probabilistic sample was going to be a challenge with this migratory population. Therefore, our sampling methodologies were revised and a sample was drawn using a combination of Proportional and Non-Proportional Quota Sampling, a purposive sampling method. The quota sampling method has been referred to as the non-probabilistic analogue of stratified random sampling in that it is typically used to assure that certain groups are adequately represented in one?s sample [Green & Browne, 2005]. Although non-random, this method of ?purposeful? sampling, which chooses individuals that are easiest to reach, is recommended for, and often used for, sampling hard-to-reach populations [Green & Browne, 2005; Kalton, 1983]. Participants in this study were recruited based on residence, age and consent.  69 Sample size The sample size required to estimate the prevalence of HIV infection among young people residing in transit camps in Gulu District, northern Uganda - such that the error of estimation is within 3% of its actual parameter with 95% confidence - was calculated to be 384. In the calculation, HIV prevalence was estimated to be 10% after taking into account the following: regional HIV prevalence estimates from the Ugandan Sero-Behavioural Survey of 8.2% among young people in northern Uganda [Ministry of Health, 2006]; the fact that Gulu District was one of the districts most impacted by conflict in northern Uganda [Dolan, 2009], and; the informed opinions of local researchers on the ground. Our resultant sample of 384 participants was further allocated in proportion to the population size of each sub-county. Population estimates were obtained from the most recent Uganda Census, last conducted in 2002 [UBOS, 2002]. The proportional sampling quota set for Ongako sub-county was 216 participants (population 14,360; 1.50% of population sampled) and for Awach sub-county it was 168 participants (population 11,160; 1.50% of population sampled). Additionally, a non-proportional quota of 50% of the sample was set with respect to the total number of male and female participants needed to allow for gender comparisons in prevalence of HIV and related vulnerabilities (i.e., 192 males, 192 females). The research team collaborated with hired community mobilizers in each site, who assisted with our sampling process and ensured that we met our predetermined sampling quotas. 3.2.2.1 Eligibility criteria We required that subjects met the following inclusion criteria at study enrolment: 1.) age 15-29; 2.) provision of consent for all study components including participation in questionnaire and HIV testing (both rapid and confirmatory testing if needed); 3.) resident in  70 a transit site in Ongako or Awach. Participants were excluded from the study if they requested to be removed from the study; however, this did not occur over the study period.  3.2.2.2 Response rate Based on previous Rakai Health Sciences Programme response rates with cross-sectional studies in Uganda [Koenig et al., 2004; Konde-Lule et al., 1997], as well as the opinions of key informants, we estimated the likely response rate to be 85%. We were, however, happily surprised to achieve a near perfect response rate, with only one individual out of 385 young people that were approached, refusing participation. We believe this is a testament to the effectiveness of our thorough community preparation process carried out prior to the commencement of participant recruitment and data collection.  3.3 Ethical Approval Ethics approval for all research described in this thesis was attained from the Providence Healthcare Research Ethics Board ? Office of Research Services, University of British Columbia, in Vancouver, Canada, and the Research and Ethics Committee for the Child Health and Development Centre (CHDC), Makerere University College of Health Sciences, in Kampala, Uganda. Approval was also granted from the Uganda National Council of Science and Technology and from the Republic of Uganda, Office of the President. 3.4 Study Team: Background, Training, Team Processes Once in the field, the candidate recruited, hired and trained a study team over a two-month period. The team consisted of: 4 research assistants (2 male, 2 female); 1 nurse; 1 HIV/AIDS counselor; 2 out-reach trauma counselors (1 male, 1 female); 1 laboratory technician; 4 community mobilizers (2 from each sub-county), and; 2 drivers. All study team members were Acholi and had worked extensively in the region before and understood the  71 complexities of working with war-affected populations. We purposely hired both male and female research assistants so that all study participants were interviewed by a same-sex team member. It has been demonstrated that same-sex interviewers help increase the comfort level of research participants while at the same time increasing the reliability/validity of self-reported behaviour concerning sensitive matters [Green & Browne, 2005]. Further, all four of our research assistants had university level education, were fluent in both English and Luo, and were experienced in working with young people and making them feel safe. Their experience and knowledge was essential to collecting credible data, as they knew the nuances of local communication and culture. For example, when participants were asked, ?What was the amount of personal income in the previous month?, most would respond ?none?. The research assistants would then probe by asking ?so how do you buy your soap and salt??, knowing that these are items normally procured with cash. This simple probe consistently elicited the productive occupations of the participants.  Prior to the commencement of data collection, all team members underwent an intensive training and preparation session. This included: a presentation and review of background information on the subject area of research; an introduction and review of research tools, including consent forms and questionnaires; a review of data collection techniques (establishing rapport, probing, clarification), which included role-play; examination of study protocols (interview, testing, referral) and familiarization with study equipment (HIV testing kits; nurse box); team planning for assuring and maintaining strict confidentiality of all participant data, and; a review and discussion of ethical conduct when conducting research with human subjects and our ethical obligations with respect to follow-up care referrals. In addition, a further component of team training included the completion of a recently  72 developed trauma-training module, by the Peter C. Alderman Foundation (PCAF). This training module is for researchers working with war-affected and traumatized individuals in northern Uganda and offers training in how best to detect and support study participants who experience distress. The training took place over a two-day period whereby representatives from the PCAF Psycho-Trauma Clinic in Gulu town came to our study office and conducted highly informative workshops with the team. We established various processes to further prepare the team and to increase ease of the data collection process. First, team members were equipped with nametags depicting our abbreviated Project name NUHAPS (Northern Uganda HIV/AIDS Prevalence Study) as well as their name and position. These were worn at all times in the field, allowing our team members to be easily recognized as working with a study that had received permission and approval from the President?s Office as well as from District authorities and sub-county officials. Second, to ensure that the date and site name were accurately entered on all study documents (consent forms, questionnaires, testing forms, referral forms, tracking forms) one research assistant was assigned to announce the date and location of sampling for the day, in the car on the way to the field. Third, team members were encouraged to have debriefing sessions in the car on the journey home from the research site. They would discuss the best and worst parts of their days as well as any observations, issues, clarifications, and meanings.  Notes would be taken and added to their field diaries, which included notes on observations, impressions, challenges and reflections. The candidate kept a similar field diary. Finally, after being in the field every weekday and some Saturdays (to capture young people who were in school during the week), Sunday was our designated ?rest-day?. Our team would meet every Sunday afternoon for brunch, after most members had attended church, to discuss  73 any issues and challenges. These meetings were always full of laughter and, if the candidate was lucky, some cooking lessons in local Acholi cuisine. 3.5 Permissions, Introductions and Community Preparation Prior to initiating fieldwork, the study team approached the office of the Resident District Commissioner (RDC) of Gulu District to make our introductions and obtain approval to proceed with our research. A meeting was held with the RDC during which we discussed the research and provided copies of our letters of permission from the Uganda National Council of Science and Technology and the President?s Office. It is important to note that this process of obtaining approval from the RDC prior to the commencement of fieldwork activities is not only respectful, but is required. Subsequently, although not required, we set up a meeting with the District Health Officer (DHO) of Gulu District. We introduced our study to him and explained the importance of our work. In hindsight, this was a very critical meeting, as the DHO?s endorsement of our study greatly aided community acceptance and increased overall participation in our study. The DHO was also instrumental in helping us overcome logistical issues in the field and created critical liaisons with various health service providers in the District. After receiving approval and endorsement from District authorities, we contacted sub-county officials (Sub-county Chiefs and Local Council Leaders) in Ongako and Awach, to introduce ourselves to them, show them our letters of permission, and seek permission and guidance to enter the transit/return areas in their sub-counties. Finally, once permission was granted and we were in the communities, prior to initiating recruitment and data collection we carried out community preparation/sensitization in the form of community meetings. The meetings were conducted with interested community members and discussed the presence of researchers at the site and raised awareness of the study. Community-level  74 leaders (camp leaders), in particular, were informed of the initiative in efforts to maximize participation and reduce the risk of stigmatizing study participants. Leadership was informed about the objectives of the study, the justification for it, and that the infection to be addressed is common. Community preparation was a critical stage of the research process because community acceptance/buy-in was vital to gaining access to our study population.  3.6 Recruitment and Consent Procedures We approached officials and community leaders in each sub-county to assist us in identifying two connected members of their community (i.e., counselors, Traditional Birth Attendants (TBA)) who would be willing to work with our study to mobilize participants on our behalf and ensure that we met our predetermined sampling quotas. After our community introductions and preparation process was complete, our community mobilizers assisted us in identifying potential study participants according to the eligibility criteria of our study (pre-selection). Although this was our primary means of (indirect) recruitment, being selected by our community mobilizer did not guarantee participation in our study. Rather, (direct) recruitment including verification of eligibility and seeking individual consent, and official enrollment in the study, was under the control of, and was handled by, our research assistants. This two-step participant recruitment process helped to guard against biases that could have arisen from having participants identified solely by our community mobilizers [MacKenzie et al., 2007]. Direct recruitment and consent procedures were also comprised of two stages. Experienced members of our research team first approached the head of household for permission to talk to and enroll prospective age-eligible household members in our study, who had been pre-identified by our community mobilizers. If the head of household did not  75 grant permission, we respected that decision and no attempt to enroll members of that household was made. If permission was granted, members of our research team then explained the study in detail to the participant and sought their individual consent for enrolment in our study.  According to Ugandan law, anyone under the age of 18 who has been married, has children or is currently pregnant is legally an emancipated minor and does not require parental assent. As such, emancipated minors were asked to provide individual informed consent. Unemancipated minors were also asked to provide individual informed consent, but their enrolment was contingent on written assent by the parent or guardian as well. When unemancipated minors were living alone in camps because their parents had re-located to the villages, we elicited the assistance of Local Council (LC) leaders to track the parents or guardians (which in some cases were the LC leaders themselves) in order to obtain consent. If the parent or guardian consented but the minor did not provide assent, that minor was not enrolled in our study. When a parent/guardian did give informed consent for an unemancipated minor, our research assistants carefully evaluated whether or not the youth themselves really wanted to participate in the study and whether they fully understood the risks and discomforts associated with participation. If there were any discrepancies, we did not enroll the minor in our study. Out of the 384 participants sampled, 277 were adults (over the age of 18), 16 were emancipated minors and 91 were unemancipated minors. We had three different consent forms, one for each ?type? of participant.  To remain consistent with other HIV research studies in the country, the consenting process was home based, whereby consent was elicited in the participant?s home environment in a private and quiet place of the participant?s choosing. This home-based  76 method has been successfully used by the Rakai Health Sciences Programme in Uganda, one of the largest HIV research, prevention and care studies in Africa, with no compromise to confidentiality. The consent process was read aloud and discussed with the participant in the respondent?s local language, Luo, to ensure that literacy and language were not barriers to providing consent. However, the consent process was also available in English if the participant preferred. All subjects were given detailed explanations of their rights as human subjects. The consent forms outlined all components of the study, the length of time of the interview process, and phone numbers and contacts of study staff should the subject have any questions. The consent form also included a section where the participant was asked to indicate (by circling ?yes? or ?no?) whether they wanted their test results back, both rapid test results and confirmatory results, if required. Each participant was made aware that their participation was purely voluntary, that they could refuse to answer any questions, and that they could leave the interview or the study at any time of their choosing. Persons who declined to participate did not experience any prejudice to their rights to healthcare or other social services or referral networks. The participant was asked to sign or fingerprint two copies of the consent form. The participant retained one copy and the study retained the other copy in the subject?s file, which was kept in a secure double locked environment (i.e., initially at our study office in Gulu Town and then at CHDC for long-term storage for 5 years).  3.7 Data Collection 3.7.1 Instrument translation process The consent forms and study questionnaires underwent a rigorous translation process to ensure that concepts and meanings remained consistent from English to the local language,  77 Luo, and that terminology used was suitable for the context, to avoid offence and/or any misinterpretation and misunderstanding. The steps for translation outlined by Wild et al. [2005] were used as a guide and our process included the following steps: 1.) forward translation from English to Luo; 2.) blinded back translation from Luo to English; 3.) review of back translation for discrepancies between translation and original meanings by the candidate; 4.) as a group, discrepancies were discussed and final versions agreed upon; 5.) each tool was piloted to ensure that it was culturally relevant and appropriate.  3.7.2 Cross-sectional demographic and behavioural questionnaire  A cross-sectional questionnaire is a collection of data at a single point in time from a specific population [Green & Browne, 2005]. This type of questionnaire is frequently used in humanitarian emergencies and was utilized in this study to provide a snapshot of the health, risk behaviour information, and HIV status of young people surviving abduction and displacement in northern Uganda. We utilized the experience and tools of the Rakai Health Sciences Programme as a starting point for the development of the demographic and behavioural questionnaire. The Rakai questionnaires, administered by trained interviewers, have been highly successful for collecting behavioural data from young people residing in Rakai District, southwestern Uganda [Koenig et al., 2004; Konde-Lule et al., 1997]. Our survey questions were also largely adapted from the Ugandan HIV/AIDS Sero-Behavioural Survey [Ministry of Health, 2006]. Our study questionnaire was tailored culturally and linguistically for post-conflict settings and reviewed by community experts before it was pilot-tested. Separate questionnaires were constructed for male and female participants, and collected data on: socio-demographic characteristics; conflict-related experiences including abduction, night commuting, IDP camp living, food security, subsistence and cross- 78 generational sex and other sexual vulnerabilities; knowledge of HIV/STIs and information on sex-related issues; sexual activity and relationships, including the cultural practice of dry sex; gender-based violence; HIV/STI prevention behaviour, including condom use, family planning and male circumcision; reproduction; alcohol use; HIV testing and care, and; health status and service utilization. The 45-page questionnaire was interviewer-administered by a same-sex ? according to interviewee - Acholi research assistant who was blind to the HIV status of the participant and bilingual in Luo and English. 3.7.2.1 Pre-testing and review After translation, the draft questionnaire was reviewed and edited by the research team. We spent six days revising the instrument, including rewording questions and removing and adding questions to ensure that the questionnaire was culturally relevant and appropriate. A convenience sample of 12 young people fitting the study?s eligibility criteria was then selected to pilot-test the questionnaire. These individuals reviewed and answered the drafted questions with an interviewer as it would be administered on a day-to-day basis during the course of the study. However, respondents were asked not only the questions from the tool, but also questions about the tool (i.e., the appropriateness of questions and how to encourage reliable responses). After the pilot testing was complete, the questionnaire was modified as necessary (i.e., re-wording or removal of questions), incorporating the comments of the participants and interviewers into a final draft of the questionnaire.  3.7.3 Biological specimen collection for HIV testing 3.7.3.1 Rapid HIV testing At the end of the questionnaire a hired nurse administered a rapid HIV Test to consenting individuals. Rapid tests are often used in resource-limited settings, including  79 humanitarian emergencies, due to their simplicity of use (i.e., no need for laboratories or storage of specimens) [Branson, 2000]. Rapid HIV testing means that counseling, testing and the receipt of results are all given on the same day. We used the INSTI HIV-1/HIV-2 Antibody Rapid HIV Test Kit (Biolytical Laboratories), which has demonstrated a test sensitivity and specificity of over 98% [Pavie et al., 2010]. At 60 seconds for a reading, INSTI Kit is the fastest HIV diagnostic assay in the world today.  A blood specimen was obtained from each participant through finger stick testing techniques using a lancet. Finger stick testing is gaining popularity because it reduces fear and anxiety, is simple to do, is time saving and requires little amounts of blood ? 2 drops [Branson, 2000]. Although our study nurse spoke highly with respect to the INSTI Kit?s ease of use, it is important to note a few challenges that we experienced while administering the test in a field setting. The lancet provided for finger-sticking was not sharp enough to pierce the finger tips (callused from digging in the fields) of some of our participants. Once we realized this challenge, our nurse requested that we purchase small needles as ?back-up?. In addition, the pipettes provided to transfer the blood drops were difficult to use when testing on uneven surfaces (covered box, mat on the ground) in the absence of tables or chairs in participants? homes.  Despite these challenges, our confirmatory testing statistics support the reported high sensitivity of the INSTI test. All positive tests identified by INSTI were confirmed positive using two enzyme-linked immunosorbent assay (ELISA) tests and, if required, a Western Blot test (i.e., no false positives). We did have two participants who at the time of interview had been previously diagnosed as HIV-positive and were on ARVs (one participant had been on ARVs for 3 years and the other for 10 months). However, when we tested them their rapid  80 test results were negative. Given this discrepancy, upon the participants? consent, we withdrew blood and sent it for confirmatory testing, which confirmed both participants were in fact HIV-negative, mirroring the rapid test results.  3.7.3.2 Confirmatory testing As briefly mentioned above, to ensure that the test result given back to the participant reflected their true HIV status, an additional sample of blood (about 4ml) was drawn through venipuncture from those testing positive with the INSTI rapid test. Specimens were transported to the CDC Laboratories at the Uganda Virus Research Institute (UVRI) in the city of Entebbe for confirmatory testing. Serum samples were tested for HIV-specific antibodies using an enzyme-linked immunosorbent assay (ELISA), the Abbott Murex HIV-1/2 ELISA (Murex Biotech Limited, United Kingdom). Reactive specimens were confirmed using a second ELISA test, Vironostika HIV Uni-Form II MicroELISA (bioMerieux, Switzerland). Samples were considered positive when both ELISA tests were positive. Any sample yielding discordant ELISA test results was subjected to Western Blot analysis (Calypte Biomedical) for definitive characterization. We replicated the Rakai Health Sciences Programme HIV confirmatory testing algorithm (detailed below), which that study has been using successfully for many years. 3.7.3.3 HIV testing algorithm After administration of the rapid test, negative test results were recorded as negative and participants requesting their results were informed that they tested negative for HIV. Positive rapid test results were recorded and reported accordingly as well. However, as noted above, those testing positive for HIV (and those with an indeterminate test result) provided an additional specimen for confirmatory testing with two ELISA tests and a Western Blot test.  81 Negative results from the first ELISA test (Murex) were recorded as negative and participants were informed that they tested negative for HIV. Reactive specimens were confirmed using a second ELISA test (Vironstica). Positive results from the second ELISA test (Vironstica) were recorded as positive and participants were informed that they tested positive for HIV. Negative and indeterminate results from the second ELISA test (Vironstica) underwent further confirmatory testing using a Western Blot test, and consequent test results were given to the participant. Figure 3.1 presents a diagram of the HIV testing algorithm employed in our study.                   82 Figure 3.1    Algorithm for HIV testing                             Negative ? Report the results as negative Positive and Indeterminate ? Do 1st ELISA Test (Murex) Result of Murex (1ST ELISA) Negative on Murex ? Report the results as negative  Positive on Murex ? Do 2nd ELISA Test (Vironstica) Result of Vironstica (2nd ELISA) Negative on Vironstica ? Do Western Blot (WB) test Indeterminate ? Do WB test Positive on Vironstica ? Report results as positive  Result of WB Negative on WB ? Report Negative  Positive on WB ? Report Positive  Start with INSTI Rapid HIV Test Kit   83 3.7.3.4 HIV testing protocol The major focus of the testing process was risk reduction and effective referral to follow-up care for HIV-positive participants. Adhering to Ugandan HIV counseling and testing protocols [Government of Uganda, 2005], the testing process began with consent for testing and pre-test counseling, followed by obtaining a blood specimen through finger stick testing techniques. When the test results were ready (approx. 60 seconds after finger-stick), the participant received post-test counseling, during which the results were given, at the participant?s request. According to Ugandan testing guidelines, the receipt of test results is completely voluntary [Government of Uganda, 2005]. The guidelines state, ?It is up to the client to decide if s/he wants to know the results of their HIV test,? [Government of Uganda, 2005]. Therefore, our HIV counselor encouraged study participants to receive their results, but only those participants opting for their results received them. To faciliate the return of confirmatory test results, tracking information (i.e., residence address, mobile phone number) was collected from participants who tested positive with the rapid test and requested their results back. After post-test counseling, if the participant requested, referrals were made for follow-up HIV care and/or psychosocial support. 3.7.3.5 Storage and transport of specimens Our research team was in the field for ten hours a day on average. While in the field, blood samples for confirmatory testing were stored in a cooler box containing a test tube rack and small ice packs. When power was available, we would re-freeze our ice packs for our cooler box overnight in a small freezer in the study office for use the next day. However, when power was intermittent or not available at all, Lacor Hospital kindly lent us a few of their ice packs, which were frozen with generator power during power outages. As needed, at  84 the end of a field day the cooler box with blood samples was transported to Lacor Hospital in Gulu town for separation and short-term storage in hospital freezers. We hired a lab technician from Lacor Hospital to oversee the receipt of samples from our study team as well as the separation and storage of samples at the hospital. Our confirmatory testing agreement with UVRI in Entebbe stipulated that all samples requiring testing were sent in one batch. Therefore, once our data collection phase was complete, we collected all separated specimens from Lacor Hospital, transferred them back into our cooler box and then put this cooler box into a metal box for extra protection during the transport of samples to Entebbe by car. The candidate, along with two of her research assistants, drove to Entebbe and personally dropped off the samples at UVRI for confirmatory testing.  3.8 Return of HIV Test Results As previously mentioned, Ugandan guidelines on HIV testing and counseling require that all testing and disclosure of results to study participants be voluntary [Government of Uganda, 2005]. Persons may decline testing but agree to counseling without testing, or they may consent to providing a sample and having it tested for HIV, without a priori agreeing to receiving their results. In addition, mandatory disclosure of results is forbidden by Ugandan Guidelines. It is up to the client to decide if they want to share the HIV results with anybody else.  ?The role of the counselor is to discuss with the client the pros and cons of disclosure. Results can only be released subject to the patient?s consent. Couples counseling is promoted, and disclosure of results is strongly encouraged, especially in the case of discordant couples,? [Government of Uganda, 2005].   85 Therefore, in keeping with the Ugandan Ministry of Health HIV testing and counseling policy, only those participants opting for their results received them, and all test results were kept completely confidential and were not divulged to any third party, including spouses, without the expressed written permission of the participant. Participants who received their results individually were encouraged to voluntarily disclose to their partner. To remain consistent with other home-based studies in Uganda, test results were given back to study participants in their home, in a private space of their choosing. All 384 study participants requested their results back from the rapid test and 89.8 percent (44/49) of those participants testing positive requested their confirmatory results back. The candidate received participants? confirmatory test results from UVRI via email two weeks after sample drop-off in Entebbe. Promptly thereafter, our study nurse and counselor tracked down those participants who had requested their test results back, using information recorded on study tracking forms. To ensure that confirmatory test results were being returned to the correct individual, study ID numbers were cross-checked between the participant?s copy of the consent form and the office copy. Over a two and a half week period at the end of January 2011, confirmatory test results were returned to 44 participants, counseling was conducted, and referrals for HIV follow-up care and/or psychosocial support were made at the participant?s request. 3.8.1 Referrals to care It is conceivable that discussion of risk behaviour, war-related experiences and/or HIV testing and receipt of results would precipitate feelings of distress. In order to mitigate potential emotional/social harm, we ensured that every study participant was offered referrals  86 for HIV follow-up care and/or psychosocial support; all referrals were made at the participant?s request. 3.8.1.1 HIV care We partnered with St. Mary?s Hospital Lacor in Gulu town to help fulfill our referral-to-care obligations for HIV-positive participants requesting HIV support and care. HIV-positive participants in this study requesting follow-up care (15 participants) were referred to one of four St. Mary?s Hospital Lacor HIV clinics. Lacor Hospital set up its first HIV clinic in 1993 and has since provided general HIV care for 6000 patients of which 3000 are currently on ARVs. In 2001, the hospital established three additional outreach HIV clinics (Pabbo, Opit and Amorro). These clinics are supported by the Uganda Ministry of Health and funded by PETFAR. All four clinics provide ARV screening, ARV drugs, and OI prophylaxis and treatment. All HIV-positive participants requesting care were referred to the Lacor HIV clinic closest to their place of residence. 3.8.1.2 Trauma care We partnered with the Peter C. Alderman Foundation (PCAF) Psycho-trauma Clinic located in Gulu Regional Referral Hospital to help facilitate and fulfill our referral-to-care obligations for participants requesting psychosocial trauma-related support and care. The Gulu Psycho-trauma Clinic opened in July 2008 and is the second PCAF Clinic in Uganda dedicated to the diagnosis, treatment and counseling of war-affected people suffering from mental trauma. We had initially planned for participants requesting trauma-related care to be directly referred to the PCAF Clinic in Gulu town. However, after discussions with the study team it became apparent that set up in this way, many participants requesting care might not actually end up accessing care due to various challenges (i.e., lack of transport options and  87 money). Unlike the three outreach Lacor HIV clinics, PCAF at the time of this study did not have any outreach clinics in the region. In addition, although PCAF had previously offered formalized outreach trauma counseling in IDP camps, they were not currently offering these services. Therefore, to help mitigate any discernable barriers to accessing psychosocial care, our plans were revised and two PCAF trauma counselors were hired and traveled with the research team to the field daily, providing trauma-related care to participants who requested it. This guaranteed that participants requesting psychosocial support received it (12 participants). The small number of participants requesting trauma care surprised us; however, many participants expressed that they thought the interview process was good for them. In the course of answering the questions, they gained a better understanding of themselves and the dynamics of HIV infection and conflict. 3.9 Summary of Interview and Testing Process Prior to the administration of the questionnaire, every participant was asked to sign or fingerprint an informed consent. Each interviewer established rapport with a same-sex prospective participant and administered a written informed consent after which s/he conducted a structured questionnaire. At the end of the interview, an HIV counselor conducted pre-test counseling with our participants and a trained nurse tested participants for HIV using the INSTI rapid HIV test. For those participants who tested positive with the rapid HIV test, an additional sample of blood was taken through venipuncture (approximately 4ml) and sent for confirmatory testing with two ELISA tests and/or a Western Blot test at UVRI in Entebbe. To facilitate the return of confirmatory results, tracking information was collected from participants who requested their results back (i.e., location of residence, mobile phone number). Post-test counseling was conducted with all participants, which included the return  88 of test results to participants requesting them. During this time, referrals for follow-up HIV care and/or psychosocial support were also made for participants when requested. To remain consistent with other home based studies in the country, all age-eligible consenting participants were interviewed by a same-sex research assistant, counseled and tested for HIV, and informed of their test results, in the participant?s home environment in a private and quiet place of their choosing. At the end of the interview and testing process, in acknowledgement of time spent on the research and therefore away from their gardens and household activities, all study participants (including participants in the pre-test group) received remuneration of 4000 UG Shillings each (approximately $2.00 USD) to compensate for time lost. This is consistent with other studies in Uganda [Koenig et al., 2004; Konde-Lule et al., 1997]. The entire interview and testing process took approximately 2-2.5 hours to complete per participant. 374 participants were interviewed and tested over a 4-month period.  3.10 Data Management and Analysis 3.10.1 Data confidentiality and security, and quality control To ensure confidentiality and security of the data, all participants were identified by unique, pre-printed numeric study ID numbers (no personal identifiers were collected). These ID numbers were used for labeling of consent, testing, referral and tracking forms, questionnaires, and test tubes containing blood samples. During the study, participants were assured that all information that they shared would be kept completely confidential. Interviews were conducted in total privacy by highly trained, same-sex interviewers, and no information was disclosed to respondents' family members, including test results. In keeping with the Ugandan Ministry of Health HIV testing and counseling policy [Government of Uganda, 2005] this study did not divulge individual HIV results to any third party, without  89 the expressed written permission of the participant. Test results were given back to participants in their home when requested, in a private space of their choice, and all test results were kept completely confidential.  Access to all data was restricted to the researchers collecting, entering and analyzing it. During the study, all hard copies of questionnaires and confidential forms (i.e., consent and testing forms) were maintained on-site in padlocked cabinets in our study office in Gulu town. Upon completion of field activities at the end of 2010, the candidate returned to Canada with all hard copies of the questionnaires (transported from Uganda in plastic-wrapped, double-locked suitcases) to complete data entry in Vancouver. All other hard copies of study documents (consent, testing, referral and tracking forms) were transported to the CHDC in Kampala for long-term storage (for 5 years). The confidentiality and security of the computerized data was maintained by storing all data files on a fire-walled, password-protected computer, and backing up all data files regularly. All information will only be used for the research purposes of this study and once the study is completed all data, including paper copies and computer files, will be destroyed. Measures taken to ensure data quality control during data collection included intensive interviewer training and periodic re-training when needed, as well as a vigorous process of pre-testing and review of the draft questionnaire. In addition, the candidate thoroughly reviewed all completed questionnaires at the end of each field day (approximately 12 questionnaires/day). The questionnaires were checked and any queries, inconsistencies, or errors were discussed with the research assistants the next morning so that, if needed, interviewers could return to re-interview subjects and correct errors immediately. Upon completion of data collection, questionnaires were coded and a data entry screen was created  90 in SPSS by the candidate, and all test and questionnaire data was double-entered by the candidate and a hired Master?s student on fire-walled, codeword-protected computers. Double data entry, a data entry quality control method, allowed for the identification and reconciliation of any inconsistencies, and thereby increased the overall integrity of the data [Simon et al., 1998]. 3.10.2 Overview of data analyses Study data, presented in Chapters 4 through 6, was analyzed using epidemiological and bio-statistical methods. All analyses were completed using SPSS, a standard statistical package. HIV prevalence and corresponding 95% confidence intervals were calculated for all study participants as well as separately for subgroups of the study population (i.e., males, females, former abductees, non-abductees, and residents of Awach and Ongako). Descriptive statistics for sample characteristics and individual level risk factors for HIV infection were obtained. Differences in demographic characteristics and behavioural risk factors between participants who were HIV-positive and HIV-negative were examined using bivariate analysis and statistical tests such as Chi-square or Fischer?s exact tests for discrete variables, and t tests or Wilcoxon rank-sum tests for continuous variables. For objectives 2 and 3, bivariate analysis was stratified by gender and abduction status respectively. Logistic regression analysis was then used to model the independent effect of individual level risk factors on HIV infection. In objective 2, separate models were constructed for male and female participants. Unadjusted and adjusted odds ratios with 95% confidence intervals were calculated for covariates of interest. Collinearity between variables in our multivariable models was assessed and dealt with appropriately. To meet our study objectives listed above, our main outcome variable was HIV status and our main independent variables of interest  91 were gender (Chapter 5) and abduction status (Chapter 6). A detailed account of the specific steps of analysis for each study objective is presented in Chapters 4 through 6 in their respective methods sections.  3.11 Data Feedback and Knowledge Translation 3.11.1 Community/District level dissemination Data feedback, the process of sharing and discussing study findings with the community and research partners, is one of the most critical stages of research initiatives. By returning results back to the community, the analyses and conclusions of researchers can be accepted or refuted, ensuring the validity of findings [Jason et al., 2004; Johannsen, 2001]. After the candidate had completed data analyses she had several discussions/meetings with her study team in Uganda via phone and computer (Skype). These meetings involved discussions of preliminary results, the meanings and implications of these results, and agreement on and acceptance of (finalization) study findings. Similar discussions occurred with the candidate?s Ugandan Committee Members, Drs. Nelson Sewankambo and Noah Kiwanuka as well as her primary supervisor, Dr. Patricia Spittal, who has carried out projects in Acholiland before and worked in Uganda for the past 15 years, to bring further understanding and validity to our findings.  The candidate plans to return to northern Uganda in the fall of 2012 for community-level knowledge translation activities, using financial support from a recently awarded CIHR Knowledge Translation Grant she received. During this time, results and implications from this study will be fed-back to the community in the form of community forums. These forums will create opportunity for dialogue and community creation of interpretation, knowledge and action.  92 3.11.2 International dissemination Results of our study will also be disseminated through scientific presentations at national and international meetings and through the write-up and submission of articles to appropriate journals. The candidate has been invited this year to share her research results through oral presentations at the Canadian Conference on HIV/AIDS Research in Montreal in April, the Canadian Public Health Association Conference in June in Edmonton and, the International AIDS Conference in July in Washington, DC. She has recently presented her research as a guest speaker at two invited talks, one at a Grand Rounds presentation in the Faculty of Medicine at UBC and the other at a Work in Progress seminar at St. Paul?s Hospital in Vancouver. Furthermore, alongside the writing of her dissertation, the candidate is preparing articles for publication based on this research for submission to the AIDS, Global Public Health, and Conflict and Health Journals.             93 3.12 Study Timeline Figure 3.2    Timeline of study activities    April 2010 May 2010 June 2010 July 2010 Aug 2010 Sept 2010 Oct 2010 Nov 2010 Dec 2010 Jan 2011 Feb 2011 Mar-June 2011 Sept-Nov 2011 Dec 2011 Jan- Dec 2012 Ethics Submission and Approval (Canada)                Ethics Submission and Approval (Uganda)                Project Initiation in Uganda                Purchase Equipment                Translate Study Instruments                 Recruit Staff and Train Interviewers                President?s Approval and Sub-county Introductions                 Community Preparation                Pilot Study Instruments                Data Collection: Ongako Sub-county                Data Collection: Awach Sub-county                Return of Confirmatory Test Results                Coding and Data Entry Screen                 Data Entry                Analysis of Data                Discussion and finalization of study results                Interpretation and Write-up                Knowledge Translation                 94 Chapter  4: HIV Prevalence and Correlates of Infection Among Young People in Post-Conflict Gulu District, Northern Uganda1  4.1 Introduction The intersection between war, displacement and HIV/AIDS is striking in northern Uganda. The more than two decades of war between the Government of Uganda (GoU) and the Lord?s Resistance Army (LRA) has resulted in countless deaths, maiming, mass displacement, abductions of school children for conscription into the insurgent ranks, human rights violations, and the destruction of the social and economic fabric of society. The impact of the war has been cross-generational and has affected the whole population of northern Uganda, which is inhabited predominantly by people of Acholi ethnicity. Over 1.8 million people were internally displaced in northern Uganda as a result of the prolonged conflict; this accounts for over 90 percent of the population in the affected region [Republic of Uganda & WHO, 2005; Westerhaus, 2007; Mazurana & McKay, 2004; Fabiani et al., 2007a]. Nearly 70 percent of the displaced population was under 25 years of age [WCRWC, 2004]. These young people, born in the last 20 to 25 years, know no other life than war. It has been estimated that as many as 66,000 children have been abducted by the rebel army and forced to serve as child soldiers, labourers and sex slaves [Annan et al., 2006; SWAY, 2008]. These atrocities have created a generation of traumatized children possibly at a heightened risk of contracting HIV and AIDS. In 2001, the United Nations General Assembly Special Session on HIV/AIDS passed the Declaration of Commitment on HIV/AIDS, stating that ?populations destabilized by armed conflict, including refugees, internally displaced persons                                                 1 This chapter was written as an article for submission to a journal. A version of chapter 4 will be submitted for publication.  95 and in particular women and children, are at increased risk of exposure to HIV infection? [United Nations, 2001]. Conflict analysts suggest that the relationship between HIV/AIDS and conflict is a complex one [Spiegel, 2004; Mock et al., 2004; Hanson et al., 2008; Jewkes, 2007; Westerhaus, 2007; Spiegel et al., 2007; Hankins et al., 2002]. Spiegel [2004] asserts that factors related to the increased vulnerability of conflict-affected populations include breakdown in social structures; lack of income and basic needs; sexual violence and abuse; increased drug use, and; lack of health infrastructure and education. However, countering these situations, Spiegel [2004] also suggests factors that might decrease HIV transmission, including reduced mobility of displaced populations, inaccessibility to high-prevalence urban areas, and improved protection, health, education and social services offered through humanitarian aid in camps. Examples from the Sudan, Sierra Leone and Angola reinforce the complexity of the relationship between conflict and HIV and suggest that conflict is either directly associated with an increase in transmission of HIV or, alternatively, it may have a protective effect by keeping persons isolated for years at a time [Kedamo et al., 2003; Kaiser et al., 2002; De Jong, 2003]. Despite the identification of conflict-related risk factors for HIV infection, little is known about the risks and risk behaviours of displaced people living in post-emergency phase camps or transit camps where continued displacement is combined with a lack of food and basic necessities. In northern Uganda, since the signing of the Cessation of Hostilities Agreement between the LRA and the GoU in 2006, IDPs have started to return to their ancestral homes. As of December 2010, it was reported that more than 90 per cent of the internally displaced population have returned to their villages of origin, while an estimated  96 182,000 IDPs remain in transit camps/sites closer to return areas [IDMC, 2010]. However, a high degree of mobility between villages of origin, transit sites, and former IDP camps has been observed among returnees, due to the lack of basic services and amenities in return areas, bringing into question the sustainability of returns and therefore the true number of formerly displaced people who have permanently returned to their villages of origin [IDMC, 2010; IDMC, 2009]. This complex post-conflict transition situation should be analyzed independently since it could further exacerbate HIV transmission as people return home in northern Uganda. In post peace accord transition, it is common for regional and municipal planners to focus on governance and rebuilding infrastructures. However, it is critical to develop post-conflict HIV intervention and antiviral treatment frameworks in tandem with the rehabilitation of primary care programmes and facilities [Hanson et al., 2008]. For post-conflict frameworks to be effective, an evidence base will be absolutely necessary. To design and implement effective HIV interventions in post-conflict settings, the assessment of who is at the highest risk of HIV infection is of vital importance, particularly in the context of continued displacement in resource-scarce, post-emergency transit camps. Similar to other conflict-affected areas around the world, HIV/AIDS has not been a high priority in northern Uganda [Salama & Dondero, 2001; Westerhaus et al., 2007; Khaw et al., 2000; Hankins, 2002; Hynes et al., 2002]. Humanitarian response and attention during the war was necessarily focused upon relief supplies, with little consideration given to HIV as a priority health issue. As a result, HIV epidemiology for the northern regions of Uganda is severely limited when compared to inroads made in operational research in the rest of the country. While NGOs have reported that HIV/AIDS may be devastating the region, data  97 describing the legacy of the conflict on HIV/AIDS, including identifying which groups are most vulnerable, has not been captured through either antenatal studies or the Ugandan HIV/AIDS Sero-Behavioural Survey, currently the only sources of HIV epidemiological data available [Westerhaus et al., 2008; Spittal et al., 2008]. This lack of population-based data has frustrated many programme planners who have specific funds to allocate to programming, but do not have the evidence base to make informed decisions and evaluate the effectiveness of programming.  This study was conducted to help fill a gap in epidemiological evidence by providing an accurate understanding of the magnitude and determinants of HIV infection among young people surviving displacement and abduction in northern Uganda. The goal was to obtain evidence-based data to assist the Government of Uganda and NGOs in identifying areas in need of focus and to support, inform and prioritize effective responses to HIV among young people in a post-conflict transition setting. Moreover, understanding the distribution of HIV within this population, including analysis of the social, biological, and behavioural factors associated with infection, will offer new insights on HIV transmission in post-conflict settings.  4.2 Methods 4.2.1 Study design and sampling  This research employed a cross-sectional study design to determine prevalence and correlates of HIV infection among young people, aged 15 to 29 years, residing in transit sites in two sub-counties in Gulu District, northern Uganda. A sample was drawn using a combination of Proportional and Non-Proportional Quota Sampling, a purposive sampling method. Although non-random, this method of ?purposeful? sampling, which chooses  98 individuals that are easiest to reach, is recommended and often used for sampling hard-to-reach populations [Green & Browne, 2005; Kalton, 1983]. Participants were recruited based on residence, age and consent. Random and systematic sampling methods were not feasible in the transit camps due to limited data on the population and the unsystematic layouts of the camps [Green & Browne, 2005; Kalton, 1983].  The sample size required to estimate the prevalence of HIV infection among young people residing in transit camps in Gulu District, northern Uganda - such that the error of estimation is within 3% of its actual parameter with 95% confidence - was calculated to be 384. In the calculation, HIV prevalence was estimated to be 10% after taking into account the following: regional HIV prevalence estimates from the Ugandan Sero-Behavioural Survey of 8.2% among young people in northern Uganda [Ministry of Health, 2006]; the fact that Gulu District was one of the districts most impacted by conflict in northern Uganda [Dolan, 2009], and; the informed opinions of local researchers on the ground. Our resultant sample of 384 participants was further allocated in proportion to the population size of each sub-county (i.e., Ongako: 216; Awach: 168). Additionally, a non-proportional quota of 50% of the sample was set with respect to the total number of male and female participants needed to allow for gender comparisons in prevalence of HIV and related vulnerabilities (i.e., 192 males; 192 females). The research team collaborated with hired community members in each site, who assisted with the sampling process by mobilizing potential study participants and ensuring that we met our predetermined sampling quotas. Direct recruitment of respondents, however, including confirmation of eligibility, seeking individual consent (parental assent was also obtained for unemancipated minors below 18 years), and official enrollment in the study, was under the control of, and was handled by, the study?s research assistants. This  99 two-step participant recruitment process helped to guard against biases that could have arisen from having participants identified solely by our community mobilizers [MacKenzie et al., 2007]. We required that subjects meet the following inclusion criteria at study enrolment: 1.) age 15-29; 2.) provision of consent for all study components including participation in questionnaire and HIV testing (both rapid and confirmatory testing if needed); 3.) resident in a transit site in Ongako or Awach. Participants were excluded from the study if they requested to be removed from the study; however, this did not occur over the study period. 4.2.2 Data collection From September to December 2010, a cross-sectional demographic and behavioural questionnaire was interviewer-administered to all study participants by a same-sex Acholi research assistant who was blind to the HIV status of participants and was bilingual in the local language of Luo and English. We utilized the experience and tools of the Rakai Health Sciences Programme as a starting point for the development of the demographic and behavioural questionnaire [Koenig et al., 2004; Konde-Lule et al., 1997] and questions were also largely adapted from the Ugandan HIV/AIDS Sero-Behavioural Survey [Ministry of Health, 2006]. Acholi research assistants were heavily involved in the design of the research instrument that was tailored culturally and linguistically for post-conflict settings and pilot-tested before commencement of data collection. Separate questionnaires were constructed for male and female participants, and collected data on: socio-demographic characteristics; conflict-related experiences including abduction, night commuting, IDP camp living, food security, subsistence and cross-generational sex and other sexual vulnerabilities; knowledge of HIV/STIs and information on sex-related issues; sexual activity and relationships, including the cultural practice of dry sex; gender-based violence; HIV/STI prevention  100 behaviour, including condom use, family planning and male circumcision; reproduction; alcohol use; HIV testing and care, and; health status and service utilization. Following each interview, a trained nurse collected blood samples. First, the INSTI HIV-1/HIV-2 Antibody Rapid HIV Test (Biolytical Laboratories) was administered to participants. To ensure that the test result given back to the participant from the rapid test reflected their true HIV status, an additional sample of blood was drawn through venipuncture from those testing positive with the rapid test. Specimens were transported to the CDC Laboratories at the Uganda Virus Research Institute (UVRI) in the city of Entebbe for confirmatory testing. Serum samples were tested for HIV-specific antibodies using an enzyme-linked immunosorbent assay (ELISA), the Abbott Murex HIV-1/2 ELISA (Murex Biotech Limited, United Kingdom). Reactive specimens were confirmed using a second ELISA test, Vironostika HIV Uni-Form II MicroELISA (bioMerieux, Switzerland). Samples were considered positive when both ELISA tests were positive. Any sample yielding discordant ELISA test results was subjected to Western Blot analysis (Calypte Biomedical) for definitive characterization.  Informed consent was obtained from all young people and parental assent was also obtained for unemancipated minors aged 15 to 17 years. All interviews and testing took place in a private and quiet place of the participant?s choosing and were conducted anonymously with no names or personal identifiers recorded. Adhering to Ugandan testing guidelines, participants were encouraged to receive their test results; however, only those participants opting for their results received them and receiving a result was not a requirement of participating in the study. If a young person indicated in the pre-test counseling process that s/he wanted her/his confirmatory test results back, the nurse collected tracking information (i.e., residence address, mobile phone number) to help facilitate the return of those results,  101 once they were received. After post-test counseling, referrals were made for follow-up HIV/AIDS care and/or psychosocial support at the participant?s request. As compensation for their time spent on the research and therefore away from their gardens and household activities, participants received remuneration of 4000 UG Shillings each (approximately $2.00 USD). Ethics approval for this study was obtained from the Providence Healthcare Research Ethics Board ? Office of Research Services, University of British Columbia, in Vancouver, Canada, and the Research and Ethics Committee for the Child Health and Development Centre (CHDC), Makerere University, College of Health Sciences in Kampala, Uganda. Approval was also granted from the Uganda National Council of Science and Technology and from the Republic of Uganda, Office of the President. 4.2.3 Explanatory variables Variables of interest were grouped into 6 categories: Demographics and background information; Sexual activity/practices & relationships; Gender-based violence; Survival/livelihood activities & food security; HIV/AIDS prevention & condom use, and; Health status. Demographic characteristics considered in the analyses included: age; gender; school status; sub-county of residence (Awach vs. Ongako); duration of IDP camp living (more than 10 years vs. 10 years or less); marital status; age at first marriage; history of abduction by the rebel army, and; night commuting. Marriage was defined to include traditional, civil, or religious marriages and, consensual unions while night commuting was defined as ?leaving your family hut at night to sleep elsewhere due to security and privacy concerns?.   102 Sexual activity/practices and relationship behaviours included a series of variables related to sexual debut, including age of sexual debut, non-consensual sexual debut, and age of first sex partner (10 or more years older vs. same age). Other sexual activity behaviours/practices considered in our analyses included condom use at last sexual encounter, alcohol consumption before last sexual encounter, and the practice of dry sex, measured by asking participants ?Have you ever had sex when your (partner?s) vagina is dry?? Gender-based violence variables included ever having experienced physical, sexual or verbal abuse from sexual partners, ever having been raped, and age of perpetrator (10 or more years older vs. same age) if so. Survival/livelihood activities and food security variables considered in the analyses included: having enough food to eat in the previous 12 months, currently experiencing lack of food and/or water, and having been involved in survival sex work, defined as receiving food, shelter, money or gifts for sex.  HIV/AIDS prevention and condom use behaviours included: perceived ability to protect oneself from HIV infection; ability to say no to sex if one does not like it; number of times tested for HIV in lifetime; knowledge of sexual partner?s HIV status; having ever used a condom, and; consistent condom use (always vs. sometimes or never). Risk factors regarding health status considered in the analyses included ever having imbibed alcohol, ever having imbibed alcohol before sex, and having STI symptoms in the previous 12 months. 4.2.4 Statistical analysis All analyses were conducted using SPSS Version 19.0. Point estimates of HIV prevalence and corresponding 95% confidence intervals were calculated separately for specified groups of interest, including: all participants together; female and male participants;  103 participants from Awach and Ongako, and; participants who had been abducted by the LRA and those who had not. Descriptive statistics (frequencies, proportions, means and standard deviations, medians and ranges) were obtained for sample characteristics and risk factors of interest. A bivariate analysis was conducted examining differences in demographic characteristics; sexual behaviours; experiences of gender-based violence; risk factors regarding survival/livelihood activities and food security; HIV/AIDS prevention and condom use behaviours, and; health status information among participants who were HIV-positive and participants who were HIV-negative. Categorical variables were compared using Pearson?s chi-square and Fisher?s exact test when 25% or more of the expected cell frequencies in a contingency table were less than 5. For comparisons of continuous variables between participants who were HIV-positive and HIV-negative an independent samples t-test was used to compare means of normally distributed variables, while medians of non-normally distributed variables were compared using the non-parametric Wilcoxon rank sum test. Logistic regression analysis was conducted to examine the independent effect of demographic characteristics and behavioural risk factors on HIV infection. Unadjusted and adjusted odds ratios were calculated for covariates of interest with 95% confidence intervals. Variables were included for unadjusted regression analysis based on significance at the p<0.05 level in bivariate analyses. The adjusted model included all variables that were statistically associated with HIV infection at a significance level of p<0.05 in unadjusted analyses as well as gender. Since ?ever married? and ?school status? were found to be correlated, only school status was entered into the model because this variable was hypothesized a priori to have a protective effect on HIV infection. Similarly, since ?ever  104 having been raped? and ?non-consensual sexual debut? were found to be correlated, only the latter variable was entered into the regression model. All reported p-values are two-sided.  4.3 Results 4.3.1 Sample characteristics A total of 384 young men and women were recruited to participate during the period of September to December 2010. Only one individual, out of 385 young people approached, declined to participate in the study. All 384 participants completed an interviewer-administered questionnaire and provided a blood specimen(s) for HIV antibody testing. All participants (100%) requested to receive the results of their rapid HIV test and approximately 90% (44/49) of participants testing positive requested to receive their confirmatory testing results.  Socio-demographic characteristics and background information The socio-demographic characteristics and background information for the 384 respondents are presented in Table 4.1. The median age of participants was 20 years and our sample had an equal number of young men (n=192) and young women (n=192). One hundred and sixty-eight respondents were residents of Awach sub-county and 216 were residents of Ongako sub-county. All participants were living in transit sites at the time of data collection, with over 40% having lived in ?transition? for 1 to 2 years. The median distance from transit site to participant?s village of origin was 7 km. Nearly 25% of participants intended to remain in their transit site for 1 to 2 years. Five percent of young people sampled were living in a child-headed household arrangement. Sixty percent of respondents had been married at some point in their lives and 43% of these marriages were polygynous (i.e., having more than one wife at a time). Median age at first marriage was 17 years. At the time of data  105 collection, 25% of participants were in school, while over 70% had been in school previously but had subsequently dropped out. Lack of money for fees and school materials (i.e., uniforms, books, pencils), was cited as the main reason for dropping out of school. Seventy-one percent of respondents indicated subsistence farming as their main means of livelihood, 9% indicated petty trade/casual labour, and 3% indicated brewing alcohol. Sixty percent of participants reported a monthly income of less than 25,000 Ugandan shillings (~$12 USD). Forty percent of respondents were currently experiencing a lack of food and/or water and over 50% of the sample indicated that they had not had enough food to eat in the previous 12 months. Prior to moving to a transit site post-conflict, 259 (67%) participants had been living in IDP camps for more than 10 years, of whom 39 had lived in an IDP camp since birth. Three percent of respondents had never lived in an IDP camp during the war. Nearly 30% of the sample had been abducted by the LRA. Median age of abduction was 13 years. Almost 75% of young people sampled had night commuted during the war; 9% of night-commuters reported moving from their family hut to another hut in the center of their IDP camp to sleep. Over 80% of the participants were Roman Catholic and nearly all participants were Acholi.           106 Table 4.1    Socio-demographic characteristics of study participants   Characteristic No. (%) of participants N = 384 Age    15-19    20-24    25-29    Median (range)  172 (44.8) 98 (25.5) 114 (29.7) 20 (15-29) Gender    Female    Male  192 (50.0) 192 (50.0) Sub-county    Awach    Ongako  168 (43.8) 216 (56.2) Duration of stay in transit site    1-6 months    7-12 months    13months- 2 years    3-5 years    More than 5 years  20 (5.2) 65 (16.9) 166 (43.2) 97 (25.3) 36 (9.4) Distance to village of origin, km, median (range) 7 (0-100) Duration of time left living in transit site    1-11 months    1-2 years    3-8 years    Forever    Don?t know  185 (48.2) 92 (23.9) 30 (7.8) 13 (3.4) 64 (16.7) Living arrangements    Child-headed household    Other  19 (4.9) 365 (95.1) Marital status    Currently married    Other    Never married    Age at 1st marriage, yr, median, (range)  150 (39.0) 82 (21.4) 152 (39.6) 17 (9-25) Polygynous marriage 100 (43.1) n=232 School status    Ever school     In school    Dropped out   374 (97.4) 96 (25.0) 278 (72.4)  107  Characteristic No. (%) of participants N = 384  Reason for school drop-out     No money for school fees    Got married    Left school during war    Pregnancy (females only)    Other  174 (62.5) 21 (7.6) 30 (10.8) 30 (10.8) 23 (8.3) Main means of livelihood    Subsistence farmer     Petty trade/Casual labour    Brew alcohol    Other  271 (70.6) 36 (9.4) 12 (3.1) 65 (16.9) Monthly income < 25,000 UGS*1 232 (60.4) Currently experience lack of food and/or water 153 (39.8) Not enough food to eat past 12 months 207 (53.9) Duration of stay in IDP camps     Never    3-5 years    5-10 years     More than 10 years    Since I was born  12 (3.1) 28 (7.3) 85 (22.1) 221 (57.6) 38 (9.9) Abducted by LRA    Female abductees    Male abductees    Age of abduction, yr, median (range) 107 (27.9) 42 (39.3) 65 (60.7) 13 (6-21) Ever night commute*2 278 (72.4) Religion    Roman Catholic    Protestant Church of Uganda    Muslim    Pentecostal Christian  311 (81.0) 47 (12.2) 14 (3.7) 12 (3.1) Tribe    Acholi    Other  376 (97.9) 8 (2.1) *1 Approximately $12USD *2 Leaving your family hut at night to sleep elsewhere due to security and privacy concerns     108 Sexual behaviour and practices Tables 4.2 and 4.3 summarize the sexual behaviour characteristics and HIV/AIDS prevention practices of the participants. Seventy-eight percent of participants had had sex before and the median age at first sexual intercourse was 16 years. Of note was that 69 (23%) of the sexually active participants indicated age of sexual debut less than 15 years of age. Nearly 40% of respondents used a condom at sexual debut and over 80% of participants? first sexual experience was consensual. Fifteen percent of participants? first sex partners were 10 or more years older than they were at the time. Sixty percent of respondents indicated that their first sexual partner?s main occupation was student and 9% indicated military/rebel soldier. Over 10% of married respondents currently had a sex partner besides their spouse. In the previous six months, nearly 70% of participants were sexually active and over 12% had sex partners from outside their community during this time period. Nearly 10% of respondents had imbibed alcohol before sex at some point and 52% of those participants had imbibed alcohol before their last sexual experience. Fifty percent of participants reported having practiced dry sex and all of these respondents had practiced dry sex at their last sexual encounter. Eleven (3.7%) participants reported having exchanged sex for food, shelter, money or gifts (i.e., survival sex). Median age at first survival sex experience was 17.5 years and the median age of partner was 48 years. With respect to gender-based violence experiences, 50% of participants had experienced physical, sexual or verbal abuse from their sex partner(s), while 20% of respondents had been raped. Median age at rape was 14 years and almost 60% of victims indicated that the perpetrator was 10 or more years older than them. Over 30% of the perpetrators? main occupation was reported to be military or rebel soldier, while 25% were subsistence agriculturalists.  109 Almost 85% of respondents thought they could protect themselves from HIV/AIDS, as shown in Table 4.3. Seventy percent of participants indicated that testing blood before engaging in sex was the most effective means of preventing HIV. Eighty-seven percent of the sample indicated that they were able to say no to sex if they did not like it. Nearly 13% of respondents perceived that it was very likely that they had been exposed to HIV. Sixty-three percent of respondents indicated easy access to free condoms in their community. One hundred and fifty-five (40%) participants indicated never having had someone demonstrate to them how to use a condom. Over 50% of respondents reported having used a condom at some point, while less than 30% of the sexually active participants reported using a condom during last sexual encounter. Consistent condom use was only reported by 27% of condom users. Over 80% of participants had had an HIV test and the median number of times tested for HIV in lifetime was 14. Eighty percent of sexually active participants indicted that they knew their partners? HIV status.                 110 Table 4.2   Sexual behaviour characteristics of study participants                         Characteristic No. (%) of participants N = 384 Sexually active (ever)    Age at first sex, yr, median (range) 301 (78.4) 16 (6-25) Condom use at first sexa 113 (37.5) Consensual intercourse at first sexa 249 (82.7) First sex partner 10 or more years oldera 51 (16.9) Main occupation of 1st sex partnera    Student    Subsistence farmer     Military/Rebel    Other  179 (59.5) 60 (19.9) 27 (9.0) 35 (11.6) Currently have sex partner besides your spouseb 17 (11.3) Sexually active past 6 monthsa    Past 6 months had sex partner(s) from outside        your community 207 (68.8)  26 (12.6)  Ever imbibed alcohol before sexa    Imbibed alcohol last sex 29 (9.6) 15 (51.7) Ever practice dry sex*1,a 152 (50.5) Practice dry sex last sexual encountera 152 (50.5) Ever survival sex work*2,a    Age at 1st survival sex, yrs, median (range)    Age of partner, yrs, median (range) 11 (3.7) 17.5 (14-28) 48 (17-53) Ever physically/sexually/verbally abused by any of your sexual partnersa   150 (49.8) Rape (ever)a     Age at rape, yr, median (range) 59 (19.6) 14 (6-24) Perpetrator 10 or more years olderc  35 (59.3) Main occupation of perpetratorc    Military/rebel soldier    Subsistence agriculturalist    Student    Other  19 (32.2)  15 (25.4) 12 (20.3) 13 (22.0) *1 Sexual intercourse without foreplay or lubrication so that the vagina is dry upon penetration *2 Exchanging sex for food, shelter, money, gifts   a Among those reporting ever having had sex (n=301)    b Among those reporting currently married (n=150)   c Among those reporting ever having been raped (n=59)  111 Table 4.3    HIV/AIDS prevention practices and perceptions of risk among study participants   Characteristic No. (%) of participants N = 384 Can protect self from HIV/AIDS 320 (83.3) Testing blood before engaging in sex most effective means of preventing HIV/STIs 212 (70.4) Able to say no to sex if do not like it 334 (87.0) Very likely been exposed to HIV 49 (12.8) Never had condom demonstration Never had condom demonstrationa 155 (40.4) 96 (31.9) Ever used condom 208 (54.2) Consistency of condom useb    Always    Sometimes or never  56 (26.9) 152 (73.1) Condom used last sexa 86 (28.6) Easy to get condoms in area 242 (63.0) Ever HIV test 314 (81.8) No. of times tested for HIV in lifetime, median (range) 14 (0-30) Know spouse?s or any partner?s HIV statusa 242 (80.4) a Among those reporting ever having had sex (n=301) b Among those reporting ever having used a condom (n=208)             112 Health status and service utilization Table 4.4 presents descriptive statistics on the health status and service utilization practices of the participants. Almost 70% of participants had on at least one occasion sought healthcare outside of their home, and the median distance from their home to healthcare location was 3 km. In the previous 12 months, nearly 60% of respondents indicated that they had had a health problem, of whom 95% sought medical advice or treatment as a result. The most common health problem indicated in the previous 12 months was malaria (73%). Thirty-five (12%) of the sexually active participants reported having had an STI besides HIV/AIDS: 20 respondents had previously had syphilis; 9 had had gonorrhea; 5 had had candidiasis, and 1 participant reported having had a genital ulcer. Nearly all participants who had ever had an STI had sought treatment for it (94.3%). Over 20% of sexually active respondents had experienced STI symptoms in the previous 12 months, of whom 70% sought treatment as a result. One hundred and eleven sexually active participants (37%) had accessed Family Planning (FP) services, of whom 93% were currently using an FP method. The three top FP methods currently being used were condoms, injections and Norplant. Fifteen percent of the sample reported past alcohol consumption, and the median age at which they began drinking was 20 years. Fifteen percent of drinkers indicated having 5 or more drinks on a typical day of drinking and the majority reported drinking beer and local waragi (gin). Over 80% of participants reported that there were no services available in their community for people who wanted help with their drinking problems. Out of the 49 positive participants identified in our study, 63.3% had accessed general HIV/AIDS care and 42.9% had taken ARVs. Over 85% of participants who indicated having taken ARVs reported 100% adherence and 28.6% reported having to pay for their ARVs. Over 85% of female  113 participants indicated having been pregnant at some point in their lives. The median age at first pregnancy was 17 years and the median number of pregnancies reported was 3. Ninety-three percent of female participants who had ever been pregnant had accessed antenatal care during their pregnancy. Nearly 7% of male participants reported having been circumcised and median age at circumcision was 12 years.                         114 Table 4.4    Health status and service utilization practices of study participants   Characteristic No. (%) of participants N = 384 Ever sought healthcare outside of home  258 (67.2) Distance of healthcare from home, km, median (range) 3 (.10-45) Health problem past 12 months    Sought healthcare for problem    Malaria past 12 months 223 (58.1) 211 (94.6) 162 (72.6)  Ever STI besides HIVa    Syphilis    Gonorrhea    Candidiasis    Genital ulcer    Sought treatment for STI 35 (11.6) 20 (57.1) 9 (25.7) 5 (14.3) 1 (2.9) 33 (94.3) Symptoms of STI past 12 monthsa    Sought treatment last time you had STI      symptoms in the previous 12 months 63 (20.9) 44 (69.8) Ever access family planning (FP) servicesa    Currently using family planning method 111 (36.9) 103 (92.8) Type of FP method currently using    Condoms    Injection    Norplant/Implants    Other Multiple responses allowed 36 (34.9) 35 (33.9) 23 (22.3) 19 (18.4) Ever imbibed alcohol    Age start drinking, yr. median (range) 58 (15.1) 20 (13-27) # of drinks per day of drinkingb       1-2       3-4       5 or more  31 (53.4) 18 (31.0) 9 (15.5) Type of alcohol consumedb       Beer       Local wine (punch)       Local Waragi (gin)       Lacoyi Multiple responses allowed  31 (53.4) 8 (13.8) 32 (55.2) 7 (12.1) No alcohol cessation services in community 309 (80.5) Ever accessed general HIV carec 31 (63.3) Ever taken ARVsc     100% adherence    Paid for ARVs 21 (42.9) 18 (85.7) 6 (28.6)  115  Characteristic No. (%) of participants N = 384 Ever pregnant (females only)a    Age at 1st pregnancy, yr, median (range)    # of pregnancies, median (range) 135 (86.5) 17 (10-22) 3 (1-6) Accessed antenatal care while pregnantd 125 (92.6) Ever circumcised (males only)    Age at circumcision, yr, median (range) 11 (5.7) 12 (0-24) a Among those reporting ever having had sex (n=301), females (n=156) b Among those reporting ever imbibed alcohol (n=58) c Among those who were HIV-positive (n=49) d Among those females who were ever pregnant (n=135)                   116 4.3.2 Comparisons among HIV-positive and HIV-negative participants All bivariate comparisons between participants who were HIV-positive (n=49) and those who were HIV-negative (n=335) are summarized in Table 4.5, grouped into six categories of interest. In bivariable analysis of demographic characteristics and background information, HIV positivity was significantly associated: with older age (26 vs. 20 years, p<0.001); not being in school (98% vs. 72%, p<0.001); residing in Awach sub-county (67% vs. 40%, p<0.001); living in an IDP camp for more than 10 years (80% vs. 66%, p=0.052), and; having been married (92% vs. 56%, p<0.001). HIV-positive participants were significantly less likely to report having experienced night-commuting (59% vs. 74%, p=0.027). While female gender was marginally associated with HIV infection (p=0.092), we found no evidence that having been abducted by the LRA was associated with HIV positivity (p=0.824). Sexual behaviour and gender-based violence characteristics positively associated with HIV infection included: non-consensual first sexual experience (38% vs. 13%, p<0.001); first sex partner being 10 or more years older (33% vs. 14%, p<0.001); having practiced dry sex (65% vs. 36%, p<0.001); having been physically, sexually or verbally abused (56% vs. 37%, p=0.014), and; having been raped (38% vs. 16%, p<0.001). A number of associations were demonstrated in bivariable comparisons of food security factors, HIV/AIDS prevention and condom use practices, and health status characteristics between HIV-positive and HIV-negative participants. HIV-positive young people were significantly more likely to be currently experiencing a lack of food and/or water (57% vs. 37%, p=0.008), and to have had STI symptoms in the previous 12 months (42% vs. 17%, p<0.001). In contrast, HIV-positive participants were significantly less likely to think that they were able to protect themselves from HIV/AIDS (53% vs. 88%, p<0.001) and to have knowledge of  117 their partner?s HIV status (38% vs. 89%, p<0.001), compared to HIV-negative participants. In addition, HIV positivity was negatively associated with median number of HIV tests in lifetime (5 vs. 15, p=0.001).                       118 Table 4.5    Comparison of socio-demographic and behavioural characteristics of HIV-positive and HIV-       negative participants     Variable No. (and%) of HIV-positive n=49 No. (and%) of  HIV-negative n=335   p value Demographics & Background Information Age, yr, median (range) 26 (15-29) 20 (15-29) <0.001 Female sex 30 (61.2) 162 (48.4) 0.092 Not in school 48 (98.0) 240 (71.6) <0.001 Awach Sub-county 33 (67.3) 135 (40.3) <0.001 More than 10 years living in camps 39 (79.6) 220 (65.7) 0.052 Ever married 45 (91.8) 187 (55.8) <0.001 Formerly abducted 13 (26.5) 94 (28.1) 0.824 Night commuter*1 29 (59.2) 249 (74.3) 0.027 Sexual Activity/Practices & Relationships Age of sexual debut, yr, median (range) 16 (8-23) 16 (6-25) 0.451 Non-consensual 1st sexa 18 (37.5) 34 (13.4) <0.001 1st sex partner 10 or more years oldera 16 (33.3) 35 (13.8) <0.001 Condom use last sexa 9 (18.8) 77 (30.4) 0.100 Imbibed alcohol last sexa 5 (10.4) 10 (4.0) 0.117 Ever practice dry sex*2, a 31 (64.6) 121 (35.8) <0.001 Gender-based Violence Ever experience physical/sexual/verbal abusea 27 (56.2) 123 (36.6) 0.014 Ever been rapeda 18 (37.5) 41 (16.2) <0.001 Perpetrator 10+yrs older 13 (72.2) 22 (53.7) 0.115 Survival/Livelihood Activities & Food Security Had enough food to eat past 12 months 18 (36.7) 159 (47.5) 0.159 Current lack of food and/or water 28 (57.1) 125 (37.3) 0.008 Ever survival sex work*3, a  3 (6.3) 8 (3.2) 0.154 HIV/AIDS Prevention & Condom Use Can protect yourself from HIV/AIDS 26 (53.1) 294 (87.8) <0.001  119   Variable No. (and%) of HIV-positive n=49 No. (and%) of  HIV-negative n=335   p value Able to say no to sex if you do not like it 39 (79.6) 295 (88.1) 0.100 No. of HIV tests, median (range) 5 (0-30) 15 (0-30) 0.001 Know partner?s statusa 18 (37.5) 224 (88.5) <0.001 Ever used a condom 28 (57.1) 180 (53.7) 0.654 Consistent condom use 8 (28.6) 48 (26.7) 0.605 Health Status Ever imbibed alcohol 7 (14.3) 51 (15.2) 0.864 Ever imbibed alcohol before sex 4 (57.1) 25 (49.0) 0.827 STI symptoms past 12 monthsa 20 (41.7) 43 (17.0) <0.001 *1 Leaving your family hut at night to sleep elsewhere due to security and privacy concerns *2 Sexual intercourse without foreplay or lubrication so that the vagina is dry upon penetration *3 Exchanging sex for food, shelter, money, gifts  a  Among those reporting ever having had sex, HIV-positive (n=48) HIV-negative (n=253)               120 4.3.3 Prevalence and determinants of HIV infection Prevalence As seen in Table 4.6, 49 (12.8%) of 384 participants tested positive for the HIV antibody (95% CI: 9.6%, 16.5%) based on double ELISA and/or Western Blot. Thirty (15.6%) female participants were HIV-positive compared with 19 (9.9%) male participants; 13 (12.1%) formerly abducted participants were HIV-positive compared with 36 (13.0%) non-abducted participants, and; 33 (19.6%) participants who were residents of Awach sub-county were HIV-positive compared with 16 (7.4%) participants who were residents of Ongako sub-county.                  121 Table 4.6    Prevalence of HIV infection among study participants             Category Prevalence Estimate (%) [95% CI]   (# Infected/Total N) All participants 12.8 [9.6-16.5]  (49/384) Females 15.6  [10.8-21.6] (30/192) Males 9.9  [6.1-15.0] (19/192) Formerly Abducted 12.1  [6.6-19.9] (13/107) Non-abductees 13.0  [9.3-17.5] (36/277) Awach 19.6  [13.9-26.5] (33/168) Ongako 7.4  [4.3-11.8] (16/216)  122 Determinants of HIV infection: Regression analysis Table 4.7 summarizes the associations with HIV infection among study participants for demographic and behavioural characteristics and other putative risk factors. In unadjusted analyses, statistically significant elevations in risk of HIV infection were noted for participants who: were older; were residents of Awach sub-county; had experienced non-consensual sexual debut; had practiced dry sex; had experienced physical/sexual/verbal abuse in their lifetime; currently were lacking food and/or water, and; had experienced STI symptoms in the previous 12 months. Marginal, but not significant, elevations in risk of HIV infection were noted for female participants and among those participants who had lived in IDP camps for more than 10 years. In contrast, statistically significant factors identified in unadjusted analyses to be protective of HIV infection included: being in school; having night commuted during the war; perception that one can protect oneself from HIV/AIDS; a greater number of HIV tests in lifetime, and; knowledge of partner?s HIV status. In multivariable logistic regression analysis, age, geographic location (Awach vs. Ongako sub-county), non-consensual first sexual experience, having practiced dry sex, and experiencing STI symptoms in the previous 12 months were independently associated with increased risk of HIV infection among young people in our study. In addition, participants who perceived that they could protect themselves from HIV/AIDS and those with a higher number of HIV tests in their lifetime were at a significantly lower risk for infection.        123 Table 4.7    Determinants of HIV infection by logistic regression Variable Unadjusted odds ratio [95% CI] Adjusted odds ratio [95% CI] Age 1.23 [1.14-1.33]  1.17 [1.05-1.32] Female gender           1.69 [0.91-3.11] *forced entry 1.54 [0.54-4.43] In school 0.05 [0.01-0.39] 0.38 [0.04-3.92] Awach sub-county 3.06 [1.62-5.77] 2.93 [1.28-6.68] More than 10 years living in camps (ref=<10 years) 2.04 [0.98-4.23] N/A Night commuter*1 0.50 [0.27-0.93] 0.69 [0.31-1.52] Non-consensual 1st sex 5.14 [2.60-10.15] 9.88 [1.70-18.06] 1st sex partner 10 or more years older (ref=same age) 3.05 [0.79-11.76] N/A Ever practice dry sex*2 3.05 [1.64-5.67] 2.31 [1.04-5.13] Experience physical/sexual/verbal abuse (ever) 2.12 [1.16-3.87] 1.09 [0.48-2.46] Currently experience lack of food and/or water 2.24 [1.22-4.11] 1.46 [0.62-3.42] Can protect yourself from HIV/AIDS 0.16 [0.08-0.30] 0.29 [0.12-0.69] No. of HIV tests in lifetime 0.94 [0.90-0.98] 0.86 [0.81-0.91] Know partner?s status 0.29 [0.15-0.54] 0.50 [0.22-1.12] STI symptoms past 12 months 4.68 [2.44-9.00] 2.36 [1.43-6.17] *1 Leaving your family hut at night to sleep elsewhere due to security and privacy concerns *2 Sexual intercourse without foreplay or lubrication so that the vagina is dry upon penetration           124 4.4 Discussion The post-conflict process, taken to mean the transition from conflict to a period of stability, recovery and reconstruction emerges as one that is not very well understood. Moreover, little is known about HIV infection risks and risk behaviours of displaced people living in resource-scarce, post-conflict phase transit camps in Africa, and the literature base that elucidates general post-conflict period risk factors for HIV/AIDS transmission is severely limited. Previous research assessing the influence of conflict on HIV infection suggests that it may have either a protective or enabling effect on HIV transmission [Spiegel, 2004; Mock et al., 2004; Hanson et al., 2008; Hankins et al., 2002]. It is unclear what the influence of the prolonged conflict in northern Uganda has been on HIV transmission; therefore, understanding the epidemic patterns at local levels is important for developing effective programme responses as former IDPs transition through the post-conflict process. Based on the HIV prevalence of 12.8% identified in this study, Gulu District is a high prevalence District in the Ugandan context. Although there are no historic District-level statistics for us to compare prevalence rates to, the Ugandan Sero-Behavioural Survey, last conducted in 2004/05, provides regional estimates of HIV infection among people aged 15 to 49. HIV prevalence was estimated at 8.2% for the whole North Central Region, much lower than what was observed in this study [Ministry of Health, 2006]. Moreover, the prevalence estimate of 12.8% identified for Gulu District in our study is nearly twice the national estimate of 6.7%, based on preliminary data from the recent Uganda AIDS Indicator Survey conducted by the Ministry of Health [Mwesigye, 2012].  We identified a large variation in HIV prevalence between sub-counties in Gulu District. This suggests that vulnerability and risk of HIV transmission may be greater in some parts of  125 the District than in others, and may be due to individual or community-level factors. Since Awach is relatively remote compared to Ongako, the mobility of the population may be a contributing factor to the observed elevated prevalence rates. Movement to and from neighbouring communities, to attend auctions and access mobile markets for household necessities, is common and may be a risk factor. In this study, 62% of participants who were resident of Awach compared to 35% of participants from Ongako, indicated travel to a mobile market in the previous 12 months. Further research is required to arrive at a better understanding of why some communities in Gulu District seem to be at higher risk than others, and tools to rapidly identify higher risk areas need to be developed. This would allow for the identification of priority areas on which to focus appropriate prevention interventions.   Other than place of residence, significant risk factors identified for HIV infection included: age; non-consensual first sexual experience; experiencing STI symptoms in the previous 12 months, and; having practiced dry sex. Although the former three factors have been shown to be associated with HIV infection in other studies from Uganda [Ministry of Health, 2006; Koenig et al., 2004; Carpenter et al., 2002], the relationship between the use of substances to reduce vaginal secretions in order to create a drier, tighter vagina (i.e., dry sex practice) and HIV infection, has never been established in Uganda. Participants who had practiced dry sex were more than twice as likely to be HIV-positive compared to those participants who had never practiced dry sex. All 152 (50.5%) participants who indicated ever having practiced dry sex also reported practicing dry sex at their last sexual encounter, illustrating the common frequency of this sexual custom. The main reasons given by research participants for engaging in dry sex was for the purpose of increasing men?s sexual pleasure and the desire of women to establish fidelity. Some young men also indicated their  126 preference for dry sex was related to their belief that vaginal fluids carry HIV and other diseases. In the past two decades, it has become increasingly apparent in both the epidemiological and, to a lesser extent, the social science literature that the association between the practice of dry sex and risk of HIV infection is of critical importance, particularly in areas heavily affected by HIV [Scorgie et al., 2009, Schwandt et al., 2006; Hyena, 1999]. Dry sex practices decrease the presence of vaginal secretions containing lactobacilli, the body?s natural defense to infection. Lack of lubrication during penetration increases the likelihood of lacerations in the vaginal wall, creating an environment susceptible to infection [Hyena, 1999]. Recent research in Kenya, South Africa and Mozambique suggest that dry sex practices may directly contradict HIV prevention messages, including the use of lubricated condoms [Scorgie et al., 2009; Schwandt et al., 2006; Bagnol & Mariano, 2008; Mehta et al., 2007; Mehta et al., 2008]. In this study, 91% of young men who indicated having practiced dry sex had never used a condom before. Our findings are particularly important in informing appropriate prevention programming for young people in northern Uganda given the general focus of most HIV prevention programmes on lubricated condoms and, more recently, microbicides. There has indeed been widespread concern among researchers and policymakers that microbicides would not be acceptable in areas where practicing dry sex was the norm [Bagnol & Mariano, 2008; Beksinska et al., 1999; Kun, 1998; Scorgie et al., 2009; McGrory & Gupta, 2002]. Our findings underscore the importance of conducting further research to test assumptions about which HIV prevention methods would or would not be acceptable, and conducting supplementary studies to gather information on user perspectives based on actual product use. At the same time, since dry sex appears to be a common cultural practice, raising  127 awareness and knowledge levels of its relationship to elevated risk of HIV infection must be a critical component of HIV prevention programming in northern Uganda. We found a positive association between non-consensual sexual debut and HIV infection, as has been reported in other studies from Africa [Koenig et al., 2004; Doll & Carballo-Dieguez, 1998]. Non-consensual first sexual experience was the most significant predictor of HIV infection among young people in this study and was reported by over 20% of young women and nearly 6% of young men. At least three plausible mechanisms have been put forward to explain the association between sexual coercion in childhood and adolescence and adverse reproductive health and HIV-related outcomes. One mechanism concerns the direct biological effects of coerced intercourse, such as unintended pregnancy, abortion, and STIs and their sequelae [Heise, Moore, & Toubia, 1995]. A second mechanism suggests that sexual violence may disempower women in negotiating safer sex and may negatively affect protective behaviours related to fertility regulation and STIs, including contraceptive use, STI treatment seeking, use of condoms, and ability to affect their partners? risk-taking behaviour [Heise, Moore, & Toubia, 1995; Maman et al., 2000]. A third mechanism suggests that experiencing trauma in childhood may increase the likelihood to subsequently engage in high-risk sexual behaviour, thus increasing the risk of contracting HIV or other STIs [Koenig et al., 2003; Stewart et al., 1996; Handwerker, 1993; Maman et al., 2000]. However, despite growing recognition of the issue and its links to HIV infection, reproductive health and HIV prevention programmes for young people rarely address the reality of coercive sex and other sexual violence [Zablotska et al., 2009]. The strong association between coerced sexual debut and HIV infection demonstrated in this study calls attention to the importance of addressing the issue of sexual coercion as an integral  128 component of HIV prevention programmes in post-conflict settings. Traditional, formulaic prevention programming emphasizing abstinence, partner reduction, and condom promotion (i.e., ABC strategy) may overlook the reality of the lives of many war-affected young people, including factors underlying their ability to choose whether or not to engage in sex [Westerhaus et al., 2008; Westerhaus et al., 2007]. Since traditional paradigms of HIV prevention are solely dependent on individual behavior change they fail to acknowledge the social determinants of HIV risk, such as poverty, political instability, war and, gender inequality, all determinants which severely limit personal choice and agency [Westerhaus et al., 2008; Westerhaus et al., 2007]. A more holistic and realistic approach would include: efforts to prevent sexual coercion by changing gender norms and improving communication and negotiation skills; providing support to victims; strengthening the legal and advocacy environment, and; training providers to help improve attitudes about, and clinical services for, young people who may have experienced coerced sex.  We also identified older aged participants and respondents who reported STI symptoms in the previous 12 months as having a higher risk of HIV infection. Over 20% of our sample reported having STI symptoms in the previous 12 months and 12% of our sample indicated having had an STI besides HIV at some point. Other studies in Africa have demonstrated that self-reported STI symptoms are associated with an increased risk of HIV infection [Obasi et al., 2001; Quigley et al., 1997; Carpenter et al., 2002]. It is important to note that presence of STI symptoms was based on self-report in this study as well, which does not allow us to capture asymptomatic infections and may be subject to recall error. Nonetheless, given the synergistic role of STIs in HIV transmission, it is imperative to prioritize STI diagnosis and treatment in post-conflict prevention programmes. Training health care workers in STI case  129 detection and management using the syndromic approach can reduce STI transmission considerably [Hankins et al., 2002].  Although a significant negative association between being in school and HIV infection was identified in unadjusted regression analysis, this association did not remain significant in the adjusted regression model. It is important to note, however, that only one HIV-positive participant in our sample was in school. Two significant protective factors for HIV infection were identified in adjusted analyses. Participants who perceived that they could protect themselves from HIV/AIDS and those with a higher number of HIV tests in their lifetime were at a significantly lower risk for infection. Respondents who perceived that they could protect themselves from HIV were 71 percent less likely to be HIV-positive. Moreover, 89% of respondents who indicated that they could protect themselves from HIV were in school. There is a large body of literature demonstrating the protective effect that being in school during conflict can have against HIV infection by not only physically removing children from potential harm for much of the day but also helping children learn skills and gather information to protect themselves, through exposure to school-level HIV/AIDS prevention interventions and information campaigns [UNICEF, 2002b; Patel, 2006; WCRWC, 2005]. It is difficult to assess whether the negative association demonstrated in this study, between HIV positivity and thinking one can protect oneself from infection, is from the information and prevention programmes offered to children in school. However, our findings suggest that HIV/AIDS information campaigns and prevention efforts for general and school-going populations should be closely coordinated so that young people both in and out of school have access to the same information and means to protect themselves.    130 We also identified that for every one-unit increase in previous HIV tests taken, the probability of HIV infection decreases by 14%. Eighty-two percent of respondents had had an HIV test before. The median number of times participants tested their blood for HIV in their lifetime was 14 and only 3 HIV-positive cases identified in our study had never had an HIV test before. It is difficult to determine whether the protective effect of testing for HIV can be explained through effective counseling and testing services or alternatively whether the effect is a result of positive cases ceasing to re-test after acquiring knowledge of their status, while negative cases continue to test. A common response from participants when asked to indicate what they thought to be the most effective means of preventing HIV/STIs was, ?testing blood with my partner before engaging in sex?. In addition, given the impoverished circumstances experienced by most northern Ugandan residents coupled with the severe lack of income-generating opportunities and other post-conflict strains, the incentives (i.e., half a bar of soap, salt, money) offered by testing drives and programmes may increase the frequency of re-testing, even among positive cases. More research is needed to better understand the mechanisms involved in the relationship between number of HIV tests taken over lifetime and HIV infection.  It is important to note that in bivariate analysis, we found no evidence that having been abducted by the LRA was associated with HIV positivity; therefore history of abduction was not a risk factor for HIV infection among young people in this study. This finding is particularly interesting as it is contrary to what NGO reports and media stories would lead one to believe [Annan et al., 2009]. Moreover, the assumed heightened vulnerability for HIV among abductees currently misinforms HIV programmatic responses for war-affected young people in northern Uganda [Blattman & Annan, 2008]. This finding will be further explored  131 in Chapter 6. Our findings are subject to several potential limitations. Attaining a probabilistic sample was a challenge with this population. Therefore we cannot discount the possibility that our recruitment method was biased towards particularly vulnerable young men and women surviving abduction and displacement in Gulu District. While we cannot rule out selection bias and its impact on our parameter estimates, given that over 90% of the population of northern Uganda was encamped during the war and Gulu District was the most heavily impacted District in the region, we are confident that our sample, because it includes residents from 2 randomly selected sub-counties in the District, is representative of conflict-affected young people living in Gulu District. Another limitation lies within the design of the study. Our data are from a cross-sectional survey and therefore cannot determine if HIV infection preceded or followed risk behaviours. The associations between HIV positivity and risk factors do not inform us of their relative temporal sequence. Prospective studies are required to make causal inferences in this regard. Finally, because the data is based on self-report we must acknowledge the limitation of the possibility of social desirability. Studies on self-reported HIV risk behaviours found that individuals are likely to falsify or under-report experiences and behaviours that are too painful to recall or are illegal or stigmatizing, to provide interviewers with what they believe to be socially desirable [De Irala et al., 1996; Latkin et al., 1993]. We attempted to minimize social desirability and increase reliability of responses through repeated assurances of confidentiality, the extensive training of Acholi interviewers, and having all participants interviewed by a same-sex research assistant. These approaches have been shown to minimize response bias and maximize reliability among respondents [De Irala et al., 1996].  132 Despite these limitations, the results of this study provide an accurate understanding of the magnitude and correlates of HIV infection among young people in post-conflict northern Uganda. Study findings contribute to filling an important gap in epidemiological evidence and are indicative of the HIV prevention programming needs of young people transitioning from IDP camp living back to their home villages. An emphasis on tailoring policies to local circumstances is required to meet the distinct challenges that young people in post-conflict northern Uganda face. HIV prevention and care programming that is both comprehensive in terms of coverage of vulnerable populations and is of sufficient scale to address the needs of young people living in both core and peripheral areas of the District is required. Furthermore, given the identified relationship between the cultural practice of dry sex and HIV infection, it is imperative for local leadership and young people to be meaningfully involved in the design and implementation of HIV prevention and care programmes that emphasize the importance of offering a continuum of responses to young people transitioning through the post-conflict process.            133 Chapter  5: Gender Differences in HIV Risk Behaviour Among Young Men and Women in Post-Conflict Gulu District, Northern Uganda2  5.1 Introduction Young people are at the centre of the global HIV/AIDS pandemic. An estimated 11.8 million young people aged 15 to 29 are living with HIV/AIDS; at least 50 percent of all new infections occur in this age group. Each day, an average of 6,000 to 7,000 young people become infected with HIV. The majority of cases occur in Sub-Saharan Africa (SSA) [United Nations Children?s Fund, 2002a], where almost three-quarters of all young people living with HIV/AIDS reside, even though only 10 percent of the world?s youth live there [UNAIDS, 1999]. The SSA region is also a part of the world that has been most impacted by conflict and internal displacement. In 2008, there were active armed conflicts in 17 of SSA?s 47 countries [International Peace Research Institute, 2009], which resulted in the displacement of an estimated 11.6 million people [UNHCR, 2008a]. Approximately half of this estimated displaced population is comprised of young people [Wessells & Edgerton, 2008].  Conflicts increase the risk and impact of HIV/AIDS among young people in several ways [Hankins et al., 2002; Mock et al., 2004; Hanson et al., 2008; Machel, 1996; Machel, 2001; Wessells & Edgerton, 2008; UNAIDS, 2001; Spiegel, 2004; Becker et al., 2008]. Conflicts dislocate communities, create flows of refugees and internally displaced persons, and seriously disrupt family life. They also bring soldiers and rebels into contact with civilians in situations where women and young girls are highly vulnerable to sexual violence and exploitation. The breakdown of basic services and psychological stress compound the                                                 2 This chapter was written as an article for submission to a journal. A version of chapter 5 will be submitted for publication.  134 situation. The magnitude of these problems has prompted considerable work among national and international facilitators to mainstream HIV/AIDS prevention and control into humanitarian responses and post-conflict reconstruction.  In the case of northern Uganda, an over two-decades-long war between the Government of Uganda and the rebel force, the Lord?s Resistance Army (LRA), resulted in the forced displacement of more than 90% of the region?s population, of whom 70% were under the age of 25 years, into internally displaced peoples (IDP) camps [WCRWC, 2004; Republic of Uganda & WHO, 2005; Westerhaus, 2007; Mazurana & McKay, 2004; Fabiani et al., 2007a]. Regional estimates from the Ugandan Sero-Behavioural Survey, one of the only sources of epidemiological evidence for northern Uganda, indicate an overall prevalence rate of 8.2% among young people aged 15 to 49, and a prevalence of 9% among young women and 7.1% among young men, comparatively higher than national prevalence estimates of 8% for females and 5% for males, and also the highest rates in the country [Ministry of Health, 2006].  Historically, much of HIV research has been driven by a need to better understand the relationship between gender and HIV infection, as AIDS has virtually become a disease suffered predominantly by women. Nearly 60% of new HIV infections in Africa occur among women, with young women being especially vulnerable [UNAIDS, 2001]. Three quarters of all HIV-positive Africans between the ages of 15 and 29 are women and, in SSA alone, 67% of young people living with HIV/AIDS are young women [UNAIDS, 2004]. These figures fuel the growing concern of international agencies, African governments and AIDS activists over the ?gendered? impact of AIDS in Africa. The primary means of HIV transmission to young women in Africa is sexual intercourse [STD/AIDS Control  135 Programme, 2003]. Women?s risk has been associated with prostitution, rape and incest, poor health, lack of access to quality reproductive health services, and limited ability to control these risks [Jewkes, 2001]. The power imbalances that heighten women and girls? sexual vulnerability and enhance their disproportionate risk for HIV/AIDS become even more pronounced during conflict and displacement [Westerhaus, 2007; Ward & Marsh, 2006]. During conflicts and post-conflict transition women are not only more exposed and vulnerable to HIV, they also have less coping capacity, as they are often not involved in planning the allocation of resources for reconstruction, including those for HIV/AIDS prevention and management [WHO, 2009]. Although HIV infection seems to disproportionately affect young women, the impact of conflict and HIV/AIDS on African men also needs to be better understood, as they, too, are suffering and dying. There are many anecdotal accounts suggesting that during high intensity hostilities, boys and men are as susceptible to sexual violence as women [USAID, 2000]. Furthermore, overall rates of HIV infection among the military, traditionally an almost exclusively male domain, are significantly above the average rate of the general population [UNAIDS, 2000; William Berg, 1984]. Gaining a better understanding of young men?s experience of risk during times of conflict will assist in identifying priority areas for post-conflict prevention programming that is responsive to their unique needs.  Despite previous analyses of risk factors for HIV infection in displaced populations experiencing conflict, little is known about the factors driving the pandemic in post-conflict countries, including the risks and risk behaviours of people living in post-emergency phase camps or transit camps where continued displacement is combined with a lack of food and basic necessities. This lack of population-based data has frustrated many post-conflict  136 programme planners who have specific funds to allocate to programming, but do not have the necessary evidence base needed to make informed HIV programming decisions and to evaluate the effectiveness of programming.  In northern Uganda, the signing of the landmark Cessation of Hostilities Agreement took place in August 2006 between the Government of Uganda and the LRA, bringing an end to an over two-decades-long war in the region. Although the search for durable solutions is ongoing, several hundred thousand internally displaced peoples (IDPs) who lived in camps during the war have begun their return to their home villages or new resettlement locations. As of December 2010, it was reported that more than 90 percent of the internally displaced population have returned to their villages of origin while an estimated 182,000 IDPs remain in transit camps/sites closer to return areas where humanitarian support has ceased and access to health care, food, water and other necessities is minimal [IDMC, 2010]. This population in transition provided a unique opportunity to begin to describe the conflict?s legacy with regards to HIV/AIDS, including identifying those citizens left most vulnerable in war?s aftermath.   To design and implement effective and appropriate HIV interventions in post-conflict settings, the assessment of who is at the highest risk of HIV infection, including the identification of gender-specific risk behaviours, is of vital importance. Understanding differences in socio-economic factors and sexual behaviour characteristics between young men and young women is key to our understanding of the spread of HIV in post-emergency situations and in mitigating the overall impact of HIV/AIDS. The objective of this study was to analyze the risk of HIV infection in relation to gender and risk behaviour among young people aged 15 to 29 years in Gulu District, northern Uganda, through an analysis of sex- 137 disaggregated data, with the goal of contributing to the evidence base needed for the Government of Uganda and NGOs to support, inform and prioritize effective responses to HIV among young people in post-conflict transition. 5.2 Methods 5.2.1 Sample A non-probability purposive sampling method was employed, using a combination of proportional and non-proportional quota sampling to identify a sample of young people aged 15 to 29 years of age residing in post-conflict transit camps in 2 randomly selected sub-counties in Gulu District (Ongako and Awach). Using the 2002 Uganda Census, our pre-determined sample size of 384 young people was allocated in proportion to the population size of each chosen sub-county. In addition, an equal number of male and female participants were included in the sample. Although non-random, this sampling method, which chooses individuals who are easiest to reach, is recommended and often used for sampling hard-to-reach populations [Green & Browne, 2005; Kalton, 1983]. Random and systematic sampling methods were not feasible in the transit camps due to limited data on the population and the unsystematic lay-outs of the camps [Green & Browne, 2005; Kalton, 1983]. Participants in both sub-counties were recruited based on residence in a transit camp, age (15-29 years) and consent, primarily through community outreach by hired study staff at each site.  5.2.2 Interview Inclusion criteria for the study required participants? consent to provide both a blood specimen to test for HIV antibodies and to complete a comprehensive structured face-to-face interviewer-administered questionnaire. The questionnaire covered demographics and war-related experiences, sexual behaviour, HIV/AIDS prevention and condom use, and health  138 status and service utilization. It was translated from English into the local language of Luo, and then translated back to English for review purposes. All participants met with a same-sex Acholi research assistant, blind to the HIV status of participants and bilingual in the local language of Luo and English, who confirmed study eligibility, explained procedures and sought informed consent, prior to the administration of the questionnaire.  Informed consent was obtained from all young people and parental assent was also obtained for unemancipated minors aged 15 to 17 years. All interviews and testing took place in a private and quiet place of the participant?s choosing and were conducted anonymously with no names or personal identifiers recorded. Adhering to Ugandan testing guidelines, we actively encouraged participants to receive their test results; however, only those participants opting for their results received them, and receiving a result was not a requirement of participating in the study. When requested by participants, referrals were made for follow-up HIV/AIDS care and/or psychosocial support. As compensation for their time spent on the research and therefore away from their gardens and household activities, participants received remuneration of 4000 UG Shillings each (approximately $2.00 USD). This study was approved by the Providence Healthcare Research Ethics Board, University of British Columbia, in Vancouver, Canada, and the Research and Ethics Committee, Child Health and Development Centre, Makerere University, in Kampala, Uganda. Approval was also granted from the Uganda National Council of Science and Technology and from the Republic of Uganda, Office of the President. 5.2.3 Laboratory methods Following the interview, a trained nurse administered the INSTI HIV-1/HIV-2 Antibody Rapid HIV Test (Biolytical Laboratories) to participants. To ensure that the test result given  139 back to the participant reflected their true HIV status, an additional sample of blood was drawn through venipuncture from those testing positive with the rapid test. Specimens were transported to the CDC Laboratories at the Uganda Virus Research Institute (UVRI) in the city of Entebbe for confirmatory testing using two enzyme-linked immunosorbent assay (ELISA) tests (Abbott Murex HIV-1/2 ELISA, Murex Biotech Limited, United Kingdom and Vironostika HIV Uni-Form II MicroELISA, bioMerieux, Switzerland) and, if required, a Western Blot analysis (Calypte Biomedical) for definitive characterization.  5.2.4 Measures Variables of interest were grouped into 6 categories: Demographics and background information; Sexual activity/practices & relationships; Gender-based violence; Survival/livelihood activities & food security; HIV/AIDS prevention & condom use, and; Health status. Demographic characteristics considered in the analyses included: age; sub-county of residence (Awach vs. Ongako); marital status; age at first marriage; school status; duration of IDP camp living (more than 10 years vs. 10 years or less); history of abduction by the rebel army, and; night commuting. Marriage was defined to include traditional, civil, or religious marriages and, consensual unions while night commuting was defined as ?leaving your family hut at night to sleep elsewhere due to security and privacy concerns?.  Sexual activity/practices and relationship behaviours included a series of variables related to sexual debut, including age of sexual debut, non-consensual sexual debut, age of first sex partner (10 or more years older vs. same age), and; condom use at first sexual experience. Other sexual activity behaviours/practices considered in our analyses included condom use at last sexual encounter, and the practice of dry sex, measured by asking participants ?Have you ever had sex when your (partner?s) vagina is dry??  140 Gender-based violence variables included ever having experienced physical, sexual or verbal abuse from sexual partners, experience of any abuse in the previous 12 months, ever having been raped, age at rape, and age of perpetrator (10 or more years older vs. same age). Survival/livelihood activities and food security variables considered in the analyses included: involvement in survival sex work, defined as receiving food, shelter, money or gifts for sex; having had enough food to eat in the previous 12 months, and; currently experiencing lack of food and/or water.  HIV/AIDS prevention and condom use behaviours included: perceived ability to protect oneself from HIV infection; ability to say no to sex if one does not like it; having ever used a condom; consistent condom use (always vs. sometimes or never); having been tested for HIV; number of times tested for HIV in lifetime, and; knowledge of sexual partner?s HIV status. Risk factors regarding health status considered in the analyses included: ever having imbibed alcohol; ever having imbibed alcohol before sex; ever having had an STI besides HIV; having STI symptoms in the previous 12 months; whether circumcised and age of circumcision; ever having been pregnant, and; age at first pregnancy.  5.2.5 Statistical analysis All analyses were conducted using SPSS Version 19.0. Point estimates of proportions positive for HIV and corresponding 95% confidence intervals were computed for the sample overall, as well as separately for females and males. Pearson?s chi-square tests, Fisher?s exact tests (if one or more expected counts were less than five) and the Wilcoxon rank sum test were used to test for differences between HIV prevalence and potential risk factors, by gender. Multivariable logistic regression analysis was conducted to determine risk factors for HIV infection and models were stratified by gender. Unadjusted and adjusted odds ratios  141 with corresponding 95% confidence intervals were calculated for covariates of interest. Variables were included for unadjusted regression analysis based on significance at the p<0.05 level in bivariate analysis. Multivariable models included only those variables found to be significant (p<0.05) in unadjusted analyses. All reported p-values are two-sided. In both the female and male regression models, since ?ever having been raped? and ?non-consensual sexual debut? were found to be correlated, only the latter variable was entered into each gender-specific model. In addition, since the variables ?age at sexual debut? and ?age of rape? were correlated among young women as well as ?ever having had an STI? and ?STI symptoms in the past 12 months?, only ?age at sexual debut? and ?ever having had an STI? were entered into the adjusted model for females. Similarly, in the regression model for male participants, since ?marital status? and ?school status? were found to be correlated, only school status was entered into the model. 5.3 Results 5.3.1 Sample characteristics An equal number of young women (n=192) and young men (n=192) were included in our sample, for a total sample size of 384 participants. Only one individual declined to participate in the study. One hundred percent of the participants requested the results of their rapid HIV test and approximately 90% of participants testing positive requested their confirmatory testing results. Bivariate associations between gender and demographics and sexual behaviour characteristics are presented in Table 5.1. Socio-demographic characteristics and background information The median age for both female and male participants was 21 years and an equal number of young women and men were sampled from each sub-county. A significantly greater  142 proportion of young women were currently married compared to young men (53% vs. 25%, p<0.001) and median age at first marriage was significantly lower among female participants (16 vs. 18 years, p<0.001). A significantly greater number of young women compared to young men in the sample indicated living in an IDP camp for more than 10 years (152 vs. 107, p<0.001) and currently living in a child-headed household arrangement (18 vs. 1, p<0.001). In addition, the proportion who reported a monthly income of less than 25,000 UGS (approx. $12 CDN) was higher among females (69% vs. 52%, p=0.023), although income was low overall. In contrast, a significantly greater proportion of young men compared to young women had been abducted by the LRA (34% vs. 22%, p=0.009) and had night commuted during the war (77% vs. 68%, p=0.040). Twenty-five percent of young people reported currently being in school, with a slightly higher proportion being young men (29% vs. 21%), although no significant difference by gender was detected. Sexual activity/practices and relationships Seventy-eight percent of 15 to 29-year-olds reported having had sex, with no significant differences by gender. Similarly, among those who reported ever having had sex, 78% reported having sex in the previous 12 months and there were no significant differences by gender. Median age of sexual debut was significantly lower among females (15 vs. 17 years, p<0.001). With respect to sexual debut circumstances, a significantly higher proportion of young women compared to young men reported that their first sexual experience was non-consensual (26% vs. 8%, p<0.001), that the main occupation of their first sex partner was ?military/rebel soldier? (13% vs. 5%, p=0.011), and that their first sex partner was 10 or more years older than them (29% vs. 4%, p<0.001). A greater proportion of young men who were currently married reported having a sex partner besides their spouse (31% vs. 2%, p<0.001)  143 compared to currently married young women. In addition, a significantly higher proportion of young men had used a condom at their last sexual encounter (38% vs. 20%, p=0.001) and young men had a greater median number of sexual partners in lifetime (3 vs. 1, p<0.001). Significantly more young women reported having imbibed alcohol at their last sexual encounter compared to young men (8% vs. 2%, p=0.025), while significantly fewer females reported discussing sex with anyone (92 vs. 127, p<0.001). No significant differences by gender were observed in the proportion of young people who indicated having ever practiced dry sex. Gender-based violence Among sexually experienced young people, a significantly greater proportion of young women compared to young men had experienced physical/sexual/verbal abuse from any of their sexual partners (62% vs. 37%, p<0.001) and had been raped (29% vs. 10%, p<0.001). In addition, median age at rape was lower among female participants (14 vs. 16 years) and a greater proportion of young women?s perpetrators were aged 10 or more years older than they (62% vs. 50%); however, these differences by gender were not statistically significant.  Survival/livelihood activities and food security A significantly larger proportion of young men (78% vs. 63%, p<0.001) indicated their main means of livelihood to be limited agricultural cultivation, while only female participants reported brewing alcohol as their main means of livelihood (n=12). Similarly, the 11 participants who reported ever having exchanged sex for food, shelter, money or gifts (i.e., survival sex) were also all female. Food insufficiency was experienced by a greater number of females than males; a significantly greater proportion of young women were currently experiencing lack of food and/or water (57% vs. 22%, p<0.001) and a significantly  144 greater proportion of men indicated having had enough food to eat in the previous 12 months (54% vs. 39%, p=0.003). HIV/AIDS prevention and condom use A significantly greater proportion of young men compared to young women perceived they could protect themselves from HIV/AIDS (92% vs. 75%, p<0.001) and were able to say no to sex if they did not like it (99% vs. 75%, p<0.001). Although significantly more young men reported ever using a condom (128 vs. 80, p<0.001), no significant differences by gender were detected for condom use in the previous 6 months. A significantly larger proportion of males indicated consistent condom use (32 vs. 19%, p=0.001); however, only 27% of sexually experienced young people overall reported using condoms consistently. Significantly more young women had been tested for HIV (171 vs. 143, p<0.001) and the median number of times tested for HIV in lifetime was significantly higher among females (15 vs. 11, p=0.010). A larger proportion of young men had knowledge of their partner?s HIV status (88%) compared to young women (74%); however, this difference was not significant.  Health status and service utilization A significantly higher proportion of young women had had a health problem in the previous 12 months (75 vs. 42%, p<0.001) and perceived that they were very likely to have been exposed to HIV (18% vs. 7%, p<0.001). Approximately 11% of females and 12% of males reported ever having had an STI, while a significantly higher proportion of females reported having had STI symptoms in the previous 12 months (35% vs. 6%, p<0.001). Twenty-seven percent of young men, compared with 4% of young women, reported ever having imbibed alcohol (p<0.001), and the overall consumption rate was 15%. Six percent of  145 young men reported having been circumcised and median age at circumcision was 12 years. Among sexually experienced young women, 87% reported having been pregnant, and median age of first pregnancy was 17 years.                         146 Table 5.1    Comparison of socio-demographic and behavioural characteristics among female and male                      participants    Variable No. (and%) of Young women n=192 No. (and%) of  Young men n=192   p value Demographics & Background Information Age, yr, median (range) 20 (15-29) 21 (15-29) 0.820 Awach Sub-county 84 (43.8) 84 (43.8) 1.000 Currently married 102 (53.1) 48 (25.0) <0.001 Age at first marriage, yr, median (range) 16 (9-22) 18 (12-25) <0.001 In school 40 (20.8) 56 (29.2) 0.059 More than 10 years living in camps 152 (79.2) 107 (55.7) <0.001 Living arrangements ? Child-headed household 18 (9.4) 1 (.5) <0.001 Monthly income based on previous month < 25,000 UGS 132 (68.8) 100 (52.1) 0.023 Formerly abducted 42 (21.9) 65 (33.9) 0.009 Night commuter*1 130 (67.7) 148 (77.1) 0.040 Sexual Activity/Practices & Relationships Sexually active 156 (81.3) 145 (75.5) 0.173 Age at first sex, yr, median (range) 15 (6-22) 17 (8-25) <0.001 Non-consensual 1st sexa 41 (26.3) 11 (7.6) <0.001 1st sex partner 10 or more years oldera 45 (28.8) 6 (4.1) <0.001 Occupation of 1st sex partner military/rebel soldiera 20 (12.8) 7 (4.8) 0.011 Condom used at 1st sexa 55 (37.9) 58 (37.2) 0.989 Sexually active past 12 monthsa 115 (73.7) 119 (82.1) 0.476 Currently have sex partner besides your spouseb 2 (2.0) 15 (31.3) <0.001 Condom used last sexa 31 (19.9) 55 (37.9) 0.001 Imbibed alcohol last sexa 12 (7.7) 3 (2.1) 0.025 No. of sexual partners in lifetime, median (range) 1 (1-12) 3 (1-300) <0.001 Discuss sex with anyone 92 (47.9) 127 (66.1) <0.001 Ever practice dry sex*2, a 77 (49.4) 75 (51.7) 0.917  147   Variable No. (and%) of Young women n=192 No. (and%) of  Young men n=192   p value Gender-based Violence Ever experience physical/sexual/verbal abusea  96 (61.5) 54 (37.2) <0.001 Experience physical/sexual/verbal abuse in previous 12 monthsc 37 (32.2) 30 (25.2) 0.347 Ever been rapeda 45 (28.8) 14 (9.7) <0.001 Age at rape, yr, median (range) 14 (6-23) 16 (11-24) 0.087 Perpetrator 10 or more years older 28 (62.2) 7 (50.0) 0.298 Survival/Livelihood Activities & Food Security Main means of livelihood ? Limited cultivation 121 (63.0) 150 (78.1) <0.001 Main means of livelihood - Brewing alcohol 12 (6.3) 0 (0) <0.001 Ever survival sex work*3, a 11 (7.1) 0 (0) 0.001 Currently experience lack of food and/or water 110 (57.3) 43 (22.4) <0.001 Had enough food to eat past 12 months 74 (38.5) 103 (53.6) 0.003 HIV/AIDS Prevention & Condom Use Can protect yourself from HIV/AIDS 143 (74.5) 177 (92.2) <0.001 Able to say no to sex if you do not like it 143 (74.5) 191 (99.5) <0.001 Ever used a condom 80 (41.7) 128 (66.7) <0.001 Consistent condom use 15 (18.8) 41 (32.0) 0.001 Condom use past 6 months 31 (38.8) 51 (39.8) 0.819 Ever HIV test 171 (89.1) 143 (74.5) <0.001 No. of HIV tests, median (range) 15 (0-25) 11 (0-30) 0.010 Know partner?s statusa 115 (73.7) 127 (87.6) 0.205 Health Status & Service Utilization Never sought healthcare outside of home 61 (31.8) 65 (33.9) 0.744 Had a health problem in past 12 months 143 (74.5) 80 (41.7) <0.001 Very likely to have been exposed to HIV 35 (18.2) 14 (7.3) <0.001  148   Variable No. (and%) of Young women n=192 No. (and%) of  Young men n=192   p value Ever imbibed alcohol 7 (3.6) 51 (26.6) <0.001 Ever imbibed alcohol before sex 4 (57.1) 25 (49.0) 0.227 Ever STI besides HIVa 17 (10.9) 18 (12.4) 0.859 STI symptoms past 12 months 54 (34.6) 9 (6.2) <0.001 Ever circumcised    Age at circumcision, yr,    median (range)  11 (5.7) 12 (0-24)  Ever pregnanta    Age at 1st pregnancy, yr,    median (range) 135 (86.5) 17 (10-22)   *1 Leaving your family hut at night to sleep elsewhere due to security and privacy concerns *2 Sexual intercourse without foreplay or lubrication so that the vagina is dry upon penetration *3 Exchanging sex for food, shelter, money, gifts  a  Among those reporting ever having had sex, females (n=156) males (n=145)  b  Among those currently married, females (n=102) males (n=48)  c  Among those reporting sex partner in previous 12 months, females (n=115) males (n=119)                149 5.3.2 Proportion of HIV-positive participants by gender As seen in Table 5.2, 49 (12.8%) of 384 participants tested positive for the HIV antibody (95% CI: 9.6%, 16.5%). HIV prevalence was 15.6% among females compared to 9.9% among males. Although the proportion positive for HIV was higher among females compared to males in this study, this difference in prevalence did not reach conventional statistical significance (p=0.092).                      150 Table 5.2    Prevalence of HIV infection among female and male study participants All Participants Prevalence Estimate (%) [95% CI] (# Infected/Total N) 12.8 [9.6-16.5] (49/384) Female Prevalence Estimate (%) [95% CI] (# Infected/Total N) Male Prevalence Estimate (%) [95% CI] (# Infected/Total N)  p value 15.6  [10.8-21.6] (30/192) 9.9  [6.1-15.0] (19/192) 0.092                 151 5.3.3 Predictors of HIV infection Bivariate associations between HIV prevalence and potential risk factors, by gender, are presented in Table 5.3. Table 5.4 presents demographics and sexual behaviour characteristics identified as being significantly associated with HIV infection in simultaneous logistic regression analyses among male and female participants. Among young men, the strongest independent predictor of HIV infection was non-consensual sexual debut [adjusted odds ratio (AOR) 3.24; 95% CI, 1.37-7.67]. While non-consensual first sexual experience was not significantly associated with HIV infection for young women in adjusted analyses, in unadjusted analysis, both non-consensual sexual debut and age at first sexual experience were found to be significantly associated with HIV positivity among females [unadjusted odds ratio (UOR) 3.66; 95% CI, 1.60-8.39; UOR, 0.79; 95% CI, 0.65-0.95, respectively]. Another independent predictor of HIV infection among males was age; for every one-year increase in age of a young man, the odds of HIV infection increased by 1.43 (95% CI, 1.12-1.82) times. Among young women, the strongest independent predictor of HIV infection was having practiced dry sex; females who reported having practiced dry sex were 7.62 (95% CI, 1.56-16.95) times more likely to be infected with HIV in comparison with women who had never practiced dry sex. In addition, young women residing in Awach sub-county were 4.84 (95% CI, 1.27-11.02) times more likely to be HIV-positive compared to young women from Ongako sub-county. Another factor strongly associated with HIV infection among females was ever having had an STI besides HIV (AOR, 4.02, 95% CI, 1.41-11.98). Although ever having had an STI was not significantly associated with HIV for men in the multivariable model, in univariate regression, young men who reported having had an STI were 6.19 (95% CI, 2.00-19.19) times more likely to be infected with HIV compared with men who never had  152 an STI. For each additional HIV test taken in lifetime, the odds of being infected with HIV decreased by 15% (AOR, 0.85; 95% CI, 0.77-0.94) for men and 18% (AOR, 0.82; 95% CI, 0.74-0.91) for women. Both young men and young women who reported that they perceived they could protect themselves from HIV/AIDS were significantly less likely to be infected with HIV (males: AOR, 0.24; 95% CI, 0.03-0.88 and females: AOR, 0.29; 95% CI, 0.09-0.95). Young women who reported having been pregnant were significantly more likely to be infected with HIV (UOR, 4.50; 95% CI, 1.31-15.50), although past pregnancies did not remain an independent predictor of HIV infection in the multivariable model. Similarly, young men who were currently in school were significantly less likely to be infected with HIV (UOR, 0.12; 95% CI, 0.02-0.92), although school status did not remain independently associated with HIV positivity in adjusted analysis. Finally, in univariate regression, young people of both sexes who reported knowledge of their partner?s HIV status were significantly less likely to be infected with HIV than young people who did not know the HIV status of their partner(s) (males: UOR, 0.33; 95% CI, 0.13-0.87 and females: UOR, 0.27; 95% CI, 0.12-0.62).           153 Table 5.3    Comparison of socio-demographic and behavioural characteristics among HIV-positive and                      HIV-negative participants stratified by gender                            Male                            Female  HIV (+) (N=19) HIV (-) (N=173)   HIV (+) (N=30) HIV (-) (N=162)  Variable N (%) N (%) p value  N (%) N (%) p value Demographics & Background Information Age, yr, median (range) 26(15-29) 20(15-29) <0.001  25(15-29) 20(15-29) <0.001 Awach Sub-county 12 (63.2) 72 (41.6) 0.072  21 (70.0) 63 (38.9) 0.002 Ever married 17 (89.5) 75 (43.4) <0.001  28 (93.3) 112 (69.1) 0.006 Age at first marriage, yr, median (range) 17(12-24) 18(12-25) 0.032  16 (9-22) 16(11-20) 0.975 In school 1 (5.3) 55 (31.8) 0.016  0 (0) 40 (24.7) 0.001 More than 10 years living in camps 14 (73.7) 93 (53.8) 0.097  25 (83.3) 127 (78.4) 0.541 Formerly abducted 8 (42.1) 57 (32.9) 0.423  5 (16.7) 37 (22.8) 0.453 Night commuter*1 11 (57.9) 137 (79.2) 0.046  18 (60.0) 112 (69.1) 0.326 Sexual Activity/Practices & Relationships Age at first sex, yr, median (range) 18(12-23) 16 (8-25) 0.270  14 (8-18) 16 (6-22) 0.039 Non-consensual 1st sexa 5 (27.8) 6 (4.7) 0.002  13 (43.3) 28 (22.2) 0.001 1st sex partner 10 or more years oldera 2 (11.1) 4 (3.1) 0.100  14 (46.7) 31 (24.6) 0.004 Condom used 1st sexa 6 (33.3) 52 (40.9) 0.117  4 (13.3) 51 (40.5) 0.008 Condom used last sexa 3 (16.7) 52 (33.1) 0.047  6 (20.0) 25 (19.8) 0.984 Ever practice dry sex*2, a 11 (61.1) 64 (50.4) 0.076  20 (66.7) 57 (45.2) 0.001 Gender-based Violence Ever experience physical/sexual/verbal abusea  8 (44.4) 46 (36.2) 0.153  19 (63.3) 77 (61.1) 0.812 Experience abuse past 12 monthsb 7 (43.8) 23 (22.3) 0.006  7 (36.8) 30 (31.3) 0.161 Ever been rapeda 5 (27.7) 9 (7.1) 0.006  13 (43.3) 32 (25.4) 0.005 Age at rape, yr, median (range) 16(12-17) 17(11-24) 0.538  12 (8-15) 14 (6-23) 0.007 Perpetrator 10 or more years older 3 (60.0) 4 (44.4) 0.245  10 (76.9) 18 (56.3) 0.268 Survival/Livelihood Activities & Food Security Ever survival sex work*3, a 0 0 ------  3 (10.0) 8 (6.3) 0.383 Currently experience lack of food and/or water 5 (26.3) 38 (22.0) 0.772  23 (76.7) 87 (53.7) 0.020  154                           Male                            Female  HIV (+) (N=19) HIV (-) (N=173)   HIV (+) (N=30) HIV (-) (N=162)  Variable N (%) N (%) p value  N (%) N (%) p value Had enough food to eat past 12 months 10 (52.6) 93 (53.8) 0.926  8 (26.7) 66 (40.7) 0.146 HIV/AIDS Prevention & Condom Use Can protect yourself from HIV/AIDS 14 (73.7) 163 (94.2) 0.009  12 (40.0) 131 (80.9) <0.001 Able to say no to sex if you do not like it 19(100.0) 172 (99.4) 1.000  20 (66.7) 123 (75.9) 0.285 Ever used a condom 15 (78.9) 113 (65.3) 0.232  13 (43.3) 67 (41.4) 0.840 Consistent condom use 4 (26.7) 37 (32.7) 0.888  4 (30.8) 11 (16.4) 0.025 Ever HIV test 17 (89.5) 126 (72.8) 0.165  29 (96.7) 142 (87.7) 0.208 No. HIV tests in lifetime, median (range) 5 (0-30) 11 (0-30) 0.010  7.5 (0-25) 15 (0-25) 0.024 Know partner?s statusa 8 (42.1) 119 (68.8) 0.020  10 (33.3) 105 (64.8) 0.001 Health Status Ever imbibed alcohol 7 (36.8) 44 (25.4) 0.285  0 (0) 7 (4.3) 0.599 Ever imbibed alcohol before sex 4 (57.1) 21 (47.7) 0.795  0 (0) 4 (57.1) ------ Ever STI besides HIVa 6 (33.3) 12 (9.4) 0.004  7 (23.3) 10 (7.9) 0.007 STI symptoms past 12 monthsa 1 (5.6) 8 (6.3) 0.903  19 (63.3) 35 (27.8) <0.001 Circumcised 2 (10.5) 9 (5.2) 0.298  ------ ------ ------ Age at circumcision, yr, median (range) 19(14-24) 12 (0-19) 0.150  ------ ------ ------ Ever pregnanta ------ ------ ------  27 (90.0) 108 (66.7) 0.010 Age at 1st pregnancy, yr, median (range) ------ ------ ------  17(13-21) 17(10-22) 0.630 *1 Leaving your family hut at night to sleep elsewhere due to security and privacy concerns *2 Sexual intercourse without foreplay or lubrication so that the vagina is dry upon penetration *3 Exchanging sex for food, shelter, money, gifts a Among those reporting ever having had sex, HIV-positive males (n=18) HIV-negative males (n=127); HIV-positive females (n=30)  HIV-negative females (n=126) b Among those reporting sex partner in previous 12 months, HIV-positive males (n=16) HIV-negative males (n=103); HIV-positive females (n=19) HIV-negative females (n=96)      155 Table 5.4    Determinants of HIV infection by logistic regression for male and female participants  Male Female Variable UOR [95% CI] AOR [95% CI] UOR [95% CI] AOR [95% CI] Age 1.34 [1.16-1.55] 1.43 [1.12-1.82] 1.18 [1.08-1.29] 1.09 [0.94-1.26] Awach Sub-county ------ ------ 3.67 [1.58-8.51] 4.84 [1.27-11.02] Married ------ ------ 6.25 [1.43-27.26] 2.31 [0.02-6.44] Age at 1st marriage 0.82 [0.67-1.01] N/A ------ ------ In school 0.12 [0.02-0.92] 0.17 [0.02-1.62] ------ ------ Night commuter*1 0.36 [0.14-0.97] 0.74 [0.33-1.64] ------ ------ Age at sexual debut ------- ------ 0.79 [0.65-0.95] 0.79 [0.56-1.11] Condom used 1st sex ------ ------ 0.34 [0.11-1.01] N/A Non-consensual 1st sex 4.94 [2.69-16.70] 3.24 [1.37-7.67] 3.66 [1.60-8.39] 1.07 [0.27-4.34] 1st sex partner more than 10 years older ------ ------ 1.36 [0.13-14.19] N/A Condom used last sex 0.29 [0.08-1.05] N/A ------ ------ Ever practice dry sex*2 ------ ------ 3.68 [1.62-8.41] 7.62 [1.56-16.95] Experience of abuse past 12 months 3.80 [1.36-10.66] 1.05 [0.26-4.23] ------ ------ Currently experience lack of food and/or water ------ ------ 2.83 [1.15-6.97] 1.07 [0.35-3.31] Can protect yourself from HIV/AIDS 0.17 [0.05-0.57] 0.24 [0.03-0.88] 0.16 [0.07-0.36] 0.29 [0.09-0.95] Consistent condom use ------ ------ 0.55 [0.09-3.00] N/A No. of HIV tests in lifetime 0.91 [0.85-0.98] 0.85 [0.77-0.94] 0.94 [0.89-0.99] 0.82 [0.74-0.91] Know partner?s status 0.33 [0.13-0.87] 0.40 [0.08-1.41] 0.27 [0.12-0.62] 0.57 [0.19-1.77] Ever STI besides HIV 6.19 [2.00-19.19] 3.21 [0.66-14.54] 4.63 [1.60-13.36] 4.02 [1.41-11.98] Ever pregnant ------ ------ 4.50 [1.31-15.50] 5.53 [0.89-14.31] *1 Leaving your family hut at night to sleep elsewhere due to security and privacy concerns *2 Sexual intercourse without foreplay or lubrication so that the vagina is dry upon penetration       156 5.4 Discussion Our results illustrate the magnitude of the HIV epidemic among young people affected by conflict in northern Uganda and emphasize the gender disparity in HIV prevalence among young women and men in this population. In this study, the proportion positive for HIV among females (15.6%) was considerably higher than the proportion positive for HIV among males (9.9%), although this difference in prevalence did not reach conventional statistical significance (p=0.092). Of note, however, are the limitations associated with significance tests and the interpretation of p-values in relation to the significance of findings [Sterne & Smith, 2001]. In this analysis, the potential for Type II error must be acknowledged in view of the relatively small numbers of young men and young women who tested positive for HIV infection. Thus, the study?s power may not have been strong enough to detect a ?true? difference in HIV prevalence between male and female participants at p<0.05.  The gender inequality in HIV prevalence among young people has been noted in a number of studies throughout SSA [Obasi et al., 2001; Laga et al., 2001; Gregson et al., 2002; Glynn et al., 2001; Auvert et al., 2001]. Results from population-based cohort studies in Masaka and Rakai Districts in southwestern Uganda demonstrate gender-specific differences in trends of HIV prevalence and incidence. Among females, the prevalence and incidence of HIV rise steadily from 15 to 24 years of age, peak between 25 and 29 years and remain high up to between 30 and 34 years, then start to decline slowly but steadily thereafter. In males, however, HIV prevalence is very low among those under the age of 17 years but begins to rise slowly through 20 to 29 years of age, peaks between 30 and 34 years, remains high through to the age of 39, and declines thereafter [Wawer et al., 1999; Kamali et al., 2003]. The higher rate of HIV among adolescent females compared to their male  157 counterparts is in part a reflection of early age of sexual debut for females, low power to negotiate safer sex, and coercive sex, all vulnerabilities that are even more pronounced in contexts of conflict and displacement [Westerhaus, 2007; Ward & Marsh, 2006].  In this study, a number of factors related to gender inequality were demonstrated that might partially explain the higher HIV prevalence among young women as compared to young men. Female participants were significantly more likely to report using condoms inconsistently and having a first sex partner who was 10 or more years older than they (measure of cross-generational sex), compared to male participants. In addition, a significantly higher proportion of young women reported not having had enough food to eat in the previous 12 months, as well as a current lack of food and/or water (measures of food insufficiency). Furthermore, all 11 participants who indicated ever having engaged in survival sex work were young women (measure of sexual coercion). Our findings call attention to the importance of addressing gender inequalities, including the imbalance of power in relationships, as an integral component of HIV prevention programmes in post-conflict settings. Traditional programming responses to HIV, emphasizing abstinence, partner reduction, and condom promotion (i.e., ABC strategy), may overlook the reality of the lives of many young people, including factors underlying their ability to choose whether or not to engage in sex and/or make safe sexual choices [Westerhaus et al., 2008; Westerhaus et al., 2007]. Efforts to increase women?s empowerment and influence in sexual decision-making, by working with men and boys to change any harmful gender norms related to sexual responsibility, decision-making, and violence, and offering safer sex negotiation and life skills training to young women, must be incorporated into HIV responses for young  158 people affected by conflict, to ensure that young men and young women have equal ability to protect themselves. The goal of this study was to provide policymakers involved in the development of HIV/AIDS programmes in post-conflict northern Uganda with an evidence base and strategic information to effectively plan, evaluate, design and implement new strategies and prevention interventions for young people. Therefore, although we did not find a statistically significant relationship between HIV positivity and gender in this study, our analyses of the risk of HIV infection in relation to gender and the identification of similarities and differences in risk behaviour among young men and women remains critically important for the planning and prioritization of appropriate gender-sensitive responses to HIV among young people affected by conflict.  Two similar risk factors for HIV infection among young men and women were identified in this study. Both males and females who reported that they perceived they could protect themselves from HIV/AIDS were significantly less likely to be infected with HIV. This finding underscores the importance of ensuring young people have access to the information they need to protect themselves from HIV/AIDS. Particularly in times of post-conflict transition when efforts are often focused on rebuilding infrastructure and HIV programming offered during the conflict has either ceased or has been interrupted, it is critical to ensure that young people have access to the knowledge and skills which encourage them to avoid or reduce behaviours that carry a risk of HIV infection. Even for young people who are not yet engaging in risky behaviours, AIDS education is important for ensuring that they are prepared for situations that will put them at risk as they grow older [Bankole et al., 2007]. In order to prevent becoming infected with HIV, young people need comprehensive information  159 about how HIV is transmitted and what they can do to stop themselves from becoming infected [UNESCO, 2009; Paul-Ebhohimhen et al., 2008]. This information should be delivered without moral judgment and must be available to young people both in and out of school. Another factor associated with HIV positivity among both male and female participants was number of HIV tests in lifetime. For each additional HIV test taken, the odds of HIV infection decreased by 15% (95% CI, 0.77-0.94) for men and 18% (95% CI, 0.74-0.91) for women. The median number of times tested for HIV was significantly greater among young women (15 vs. 11 times, p=0.010). It is difficult to determine whether the protective effect of testing for HIV identified in this study for both males and females can be explained through effective counseling and testing services or, alternatively, whether the effect is a result of positive cases ceasing to re-test after acquiring knowledge of their status, while negative cases continue to test. It is of note that when participants were asked ?How can you best protect yourself from HIV/AIDS?? the majority of respondents indicated ?testing blood with my partner before sex?. Furthermore, given the impoverished circumstances experienced by most northern Ugandan residents, coupled with the severe lack of income-generating opportunities and other post-conflict strains, the incentives (i.e., half a bar of soap, salt, money) offered by testing drives and programmes may increase the frequency of re-testing, even among positive cases. The role that HIV testing may have to play in preventing infection and decreasing HIV risk in this population should be explored in further research.  This study also identified gender-specific risk factors for HIV infection. Young women who resided in Awach sub-county (vs. Ongako) who had practiced dry sex and who had had an STI besides HIV were more likely to be HIV-positive. Young women residing in a transit  160 camp in Awach sub-county were nearly five times more likely to be HIV-positive compared to young women from Ongako sub-county. This finding suggests that vulnerability and risk of HIV transmission among young women may be greater in some parts of Gulu District than in others, and may be due to individual or community-level factors. Since Awach is relatively remote and under-resourced compared to Ongako, the mobility of the population may be a contributing factor to the observed association between geographic location and HIV infection among young women. Movement to and from neighbouring communities - to attend auctions and access mobile markets to procure household necessities - is common for young women and may be a risk factor. Moreover, there is growing recognition by NGOs and the academic community that food insufficiency in times of conflict may enhance sex-related HIV vulnerabilities (i.e., survival sex, intergenerational sex, coerced sex), particularly among women and girls [Mock et al., 2004; Weiser et al., 2007; Oyefera, 2007; UNCHR, 2006; Spiegel, 2004]. In this study, a greater proportion of young women from Awach sub-county reported food insufficiency (57%) compared to young women from Ongako (35%). Further research is required to arrive at a better understanding of why young women in some communities in Gulu District seem to be at higher risk than others, and tools to rapidly identify higher risk areas need to be developed. This would allow for the identification of priority areas and population groups on which to focus appropriate gender-specific prevention interventions.   Young women in our study who reported ever having had an STI were 4 times more likely to be HIV-positive compared to women who had never had an STI. In addition, although ever having had an STI was not an independent predictor of HIV for men in adjusted analysis, in univariate regression, young men who reported ever having had an STI  161 were 6.19 times (95% CI, 2.00-19.19) more likely to be infected with HIV compared with men who had never had an STI. Established literature, together with studies from Uganda, have indicated that some STIs may act as cofactors in HIV transmission, including ulcerative (syphilis and HSV-2) and non-ulcerative (chlamydia, gonorrhea and trichomoniasis) diseases [Mermin et al., 2008; Gray et al., 1999; Quinn, 1996; Grosskurth et al., 1995; Wasserheit, 1992; Clottey & Dallabetta, 1993; Grosskurth et al., 2000; Carpenter et al., 2002]. In recent analyses of HIV transmission among monogamous HIV-discordant couples in Rakai, Uganda, the risk of HIV transmission was approximately 2-fold higher when one of the partners had Genital Ulcer Disease (GUD) than when none had GUD; the risk was almost 4-fold higher when both members of a couple had GUD [Kiwanuka et al., 2009]. It is important to note that in this study, STI presence was based on self-report, which fails to capture asymptomatic infections and may also be subject to recall error. Nonetheless, our finding underscores the importance of developing post-conflict interventions among young people that address factors influencing the probability of HIV transmission, such as STIs. Efforts to improve the diagnosis of STIs and improve access to STI treatment must be integral components of HIV prevention programmes. Another important risk factor for HIV among young women, and one that has never been established in Uganda before, is the practice of dry sex (i.e., sexual intercourse without foreplay or lubrication so that the vagina is dry upon penetration). Young women who indicated that they had practiced dry sex before were nearly 8 times more likely to be HIV-positive compared to women who had never practiced dry sex. All 77 (49.4%) females who indicated ever having practiced dry sex also reported practicing dry sex at their last sexual encounter, indicating the common frequency of this sexual practice. The main reasons  162 indicated for engaging in dry sex were increasing men?s sexual pleasure and the desire of women to establish fidelity. Common practices and substances used to reduce vaginal secretions in order to create a drier, tighter vagina, cited by young women in this study, included wiping the vagina dry with a towel and insertion of a local herb (Anyero) believed to reduce moistness in the vagina, prior to sexual intercourse. In the past two decades, it has become increasingly apparent in the epidemiological literature that the association between the practice of dry sex and risk of HIV infection is of critical importance particularly in areas heavily affected by HIV [Scorgie et al., 2009, Schwandt et al., 2006; Hyena, 1999]. Dry sex practices decrease the presence of vaginal secretions containing lactobacilli, the body?s natural defense to infection. Lack of lubrication during penetration increases the likelihood of lacerations in the vaginal wall, creating an environment susceptible to infection [Hyena, 1999]. Indeed, findings from studies in Sub-Saharan Africa by Myer et al. [2005] and Schwandt et al. [2006] confirm the relationship between vaginal practices (including dry sex) and women?s susceptibility to both HIV infection and other STIs [Myer et al., 2005; Schwandt et al., 2006]. Our findings are particularly important in informing appropriate prevention programming for young people in northern Uganda, as dry sex practices may directly contradict common HIV prevention messages, including the use of lubricated condoms and microbicides [Scorgie et al., 2009; Schwandt et al., 2006; Bagnol & Mariano, 2008; Mehta et al., 2007; Mehta et al., 2008; Beksinska et al., 1999; Kun, 1998; McGrory & Gupta, 2002]. Further research must be conducted to test assumptions about which HIV prevention methods would or would not be acceptable in an area with a norm of dry sex, and conducting supplementary studies to gather information on user perspectives based on actual product use. At the same time, since dry sex appears to be a common cultural practice,  163 raising awareness and knowledge levels of its relationship to elevated risk of HIV infection must become a regular component of HIV prevention programming among young people in northern Uganda. In this study, significant elevations in HIV risk were demonstrated among young men who were of older age and had experienced non-consensual sexual debut. Results from other studies in Uganda have demonstrated the association between older age and HIV infection among men [Wawer et al., 1999; Kamali et al., 2003]; however, in Uganda and the rest of Sub-Saharan Africa there is little evidence of a relationship between forced sexual debut and HIV, particularly among young men [Zablotska et al., 2009]. Young men who reported non-consensual sexual debut were over three times more likely to be HIV-positive compared to males who reported consensual first-time sex. The majority of research on sexual violence and HIV infection in times of conflict focuses on women and girls. However, there are many anecdotal accounts that suggest that during high intensity conflicts boys and men are as susceptible to sexual violence as women are [USAID, 2000]. Closed environments, such as IDP camps or rebels? barracks, are potentially conducive to male/male rape or other non-consensual sexual penetration [Hankins et al., 2002]. Unprotected anal intercourse is a more effective means of HIV transmission than most other forms of sexual activity [Baggaley et al., 2010; Grulich & Zablotska, 2010]. The lining of the rectum has fewer cells than that of the vagina, and therefore can be damaged more easily, causing bleeding during intercourse and thus providing a direct route into the bloodstream for infected sexual fluids or blood [Baggaley et al., 2010; Grulich & Zablotska, 2010]. In northern Uganda, it has been reported that a significant percentage of boys and men are indeed victims of sexual violence [Roberts et al., 2008; Sebunya, 1996; Uganda Child Rights NGO Network, 2004; World Vision,  164 2007]. In this study, 37% of sexually experienced young men indicated having been abused by a sexual partner at some point, 25% indicated abuse in the previous 12 months and 10% had been raped. Out of the 14 cases of rape reported by young men, 11 (79%) occurred at sexual debut. Furthermore, with respect to young men?s first sexual experience, out of the 11 males who indicated non-consensual first-time sex, 9 (82%) were former abductees, 6 (55%) reported that their first sex partner was 10 or more years older than them, and 7 (64%) reported the occupation of their first sex partner to be military/rebel soldier (who was most likely of the male gender, given the gendered hierarchy of militaries/rebel groups). It is difficult to determine with certainty that the relationship between HIV infection and non-consensual sexual debut among young men observed in this study was related to their experience of abduction and forced exposure to unsafe sexual circumstances while in the bush. Our findings underscore the importance of conducting further research to better understand the impact of conflict on men?s susceptibility to sexual violence. In the meantime, however, post-conflict prevention programmes addressing sexual violence must recognize that males are sometimes also victims and therefore must be included in programming responses that are sensitive to their needs and their experiences of rape. Our findings are subject to several potential limitations. Attaining a probabilistic sample was a challenge with this population. Therefore, we cannot discount the possibility that our recruitment method was biased towards particularly vulnerable young men and women surviving abduction and displacement in Gulu District. While we cannot rule out selection bias and its impact on our parameter estimates, given that over 90% of the population of northern Uganda was encamped during the war and Gulu District was the most heavily impacted District in the region, we are confident that our sample including residents from 2  165 randomly selected sub-counties in the District is representative of conflict-affected young people living in Gulu District. Another limitation lies within the design of the study. Given the cross-sectional nature of this study, we cannot determine if HIV infection preceded or followed risk behaviours. The associations between HIV positivity and risk factors do not inform us of their relative temporal sequence. Prospective studies are required to make causal inferences in this regard. Nevertheless, this study provides valuable information for better understanding the scale and scope of HIV infection among conflict-affected young people in northern Uganda. A further limitation affects all sexual behaviour questionnaires and originates in the nature of self-reported data. Studies on self-reported HIV risk behaviours found that individuals are likely to falsify or under-report experiences and behaviours that are too painful to recall or are illegal or stigmatizing, to provide interviewers with what they believe to be socially desirable [De Irala et al., 1996; Latkin et al., 1993]. We attempted to minimize this limitation and increase reliability of responses through repeated assurances of confidentiality, the extensive training of Acholi interviewers, and having all participants interviewed by a same-sex research assistant. These approaches have been shown to minimize response bias and maximize reliability among respondents [De Irala et al., 1996]. Our findings indicate that HIV prevalence is high among young people in northern Uganda and that the proportion positive for HIV are greater among young women compared to young men, although this difference is not statistically significant. This study demonstrated that young men and women experience vulnerability to HIV infection in different ways, although it is unlikely that any given one of the risk factors acts in isolation to increase HIV risk; it is more probable that they are interdependent. Study findings underscore the importance of involving young people in developing post-conflict responses to HIV that  166 address their gender-specific vulnerabilities and prevention needs. HIV prevention programmes must continue to promote partner reduction and consistent condom use while also addressing contextual factors that make it difficult for young people to implement behaviour change (e.g., gender inequalities). Post-conflict HIV/AIDS programme planners should collect and use sex disaggregated data to monitor and evaluate impact of programming on different populations, build capacity of key stakeholders to address gender inequalities, facilitate meaningful participation of young people, and allocate resources for programme elements that address gender inequalities. In addition, strengthening interventions that reduce the probability of HIV transmission, such as improved access to STI treatment and provision of appropriate prevention means that are cognizant of cultural sexual practices (i.e., dry sex), is extremely critical. Moreover, HIV responses that address sexual violence among young people must recognize that men are also victims of sexual violence. Therefore, it is essential that programming be inclusive of males and sensitive to their needs.             167 Chapter  6: Comparison of HIV-Related Vulnerabilities Between Formerly Abducted Child Soldiers and Non-Abducted Young People in Post-conflict Gulu District, Northern Uganda3  6.1 Introduction Approximately 250,000 young people under the age of 18 years are currently actively involved, as child soldiers, in conflicts in 14 countries or territories across the globe [Ertl et al., 2011]. In northern Uganda, the over two decades of civil war between the rebel group, the Lord?s Resistance Army (LRA), and the Government of Uganda (GoU) and its military, the Ugandan People?s Defence Forces (UPDF), has affected the whole population and the impacts of the civil war continue to reverberate across generations. The civilian population suffered indiscriminate killings and maimings, widespread forced displacement, various forms of sexual and gender-based violence, destruction of the social and economic fabric of society, and the mass abduction of children to become fighters, forced labourers, and sex slaves [Liebling-Kalifani et al., 2007; Bolton et al., 2007; Westerhaus et al., 2007; Human Rights Watch, 2005a; Allen, 2006b; Van Acker, 2004]. Evidence collected through the UNICEF-sponsored Survey of War-Affected Youth (SWAY) estimated that as many as 66,000 young people between the ages of 14 and 30 were abducted by the LRA [Annan et al., 2006; SWAY, 2008]. These atrocities, and the accompanying widespread violation of human rights, have left an entire generation of young people traumatized and at a heightened risk of contracting HIV/AIDS [United Nations, 2001]. In July 2006, after years of intermittent peace negotiations, a new round of talks between the Ugandan government and the LRA opened in Juba, the capital of the now South Sudan.                                                 3 This chapter was written as an article for submission to a journal. A version of chapter 6 will be submitted for publication.  168 Shortly afterwards, in August 2006, the two parties signed a landmark Cessation of Hostilities Agreement [Dolan, 2009]. Over the next two years, further agreements were reached on comprehensive solutions, reconciliation and accountability, and disarmament. However, despite this substantial progress, the LRA?s elusive leader Joseph Kony failed to attend in person the signing of a final peace agreement in April 2008. Although the Juba Peace Process faltered at the final stage, it ushered in a period of significantly improved security for the citizens of northern Uganda, allowing the government to lift restrictions on freedom of movement. As a result, Internally Displaced Persons (IDPs) who were forcibly encamped at the height of the conflict were encouraged to move out of primary camp settings, either back to their home villages or to transit camps, smaller camps closer to return areas. By June 2010 it was reported that 108 of the 121 officially recognized IDP camps in the Acholi sub-region had been closed and as of December 2010, more than 90 percent of the 1.8 million IDPs had returned to their villages of origin while an estimated 182,000 remained in transit camps [UN OCHA, 2010b; IDMC, 2010].  During and after the conflict, communities in northern Uganda have had to deal with large numbers of formerly abducted children, adolescents and young adults returning home after their rescue, escape or release from the bush. The successful reintegration of these former child soldiers continues to be a major challenge [Ertl et al., 2011]. Reintegration programming in northern Uganda has been greatly influenced by the fears of traumatization, dislocation, and a ?lost generation? of formerly abducted young people. Non-Governmental Organizations (NGOs), which provide the majority of reintegration efforts, tend to view former abductees strictly in terms of their psychological trauma, and most programming therefore focuses on providing broad-based psychological assistance [Blattman & Annan,  169 2008]. On an individual level, viewing former abductees through a psychological trauma lens risks stigmatization, potentially hindering abductees? acceptance by their community upon return from the bush, hence compromising the success of the reintegration process [Blattman & Annan, 2008; Annan et al., 2009]. Ethnographic evidence suggests that resilience rather than psychological trauma is the norm among young ex-combatants [Boothby et al., 2006; Shepler, 2005; Wessells, 2006a], while evidence from a recent survey-based assessment of the impacts of abduction among young people in northern Uganda suggests that the most pervasive and arguably largest impact of abduction is on education and livelihoods rather than physical or psychological trauma [SWAY, 2007; Blattman & Annan, 2008; Annan et al., 2006]. The broad-based impact of forcible recruitment upon education comes as a consequence of time spent with the rebel group in the bush rather than in school. The impact is greatest among long-term abductees, male and female, who attain one to two fewer grades on average than non-abducted young people, and are more than twice as likely to be illiterate (especially among males) [SWAY, 2007; Blattman & Annan, 2008; Annan et al., 2006]. The education of women who return from the LRA with children is even more severely affected; unlike other abductees, these young mothers almost never go back to school upon return, in large part because of child care responsibilities [SWAY, 2008; Annan et al., 2009]. NGO reintegration programming focused on providing ?psychosocial care? and responses to mitigate psychological trauma among former abductees is exclusive to former child soldiers and is not extended to other war-affected young non-abductees. Addressing the needs of former abductees is unquestionably important, as they comprise a substantial proportion of the post-conflict population. However, the exclusivity of these reintegration programmes may have in and of themselves resulted in the needs of thousands of non- 170 abductees, who have also suffered terrible impacts due to the war, being overlooked [Spittal et al., 2008; Patel et al., 2011]. Thus, it is necessary to pose the question: ?what about the young people who were not abducted but were raped, experienced lack of food or water, suffered ill health without medical care, and endured family separation and/or the death/murder of a family member (all extremely traumatic events)??  In northern Uganda, an understanding of abduction experiences is not only key to the development of effective reintegration programming, it is also critical for the planning and development of post-conflict programming for non-abductees. The LRA?s recruitment tactics provide a unique opportunity to identify the lasting impacts of abduction and the gaps to be filled by reintegration programmes. Unlike most other conflict contexts where ex-fighters are a selected segment of the population - including those who chose to join, those screened by army officials, and those more vulnerable to abduction - in northern Uganda, LRA recruitment was large-scale, involuntary, indiscriminate and independent of all of a young person?s characteristics other than age [Blattman & Annan, 2008]. Hence, there appear to be no differences in pre-abduction wealth, education, and orphaning between young people who were abducted and those who were not [Blattman & Annan, 2008]. As a result, a comparison of abductees to non-abductees allows an accurate assessment of the long-term impacts of combat and the appropriateness of current programming. The objective of this study was to determine the effects of abduction and living in the bush on prevalence of HIV and risk behaviours among former abductees aged 15 to 29 years in Gulu District, northern Uganda, including a comparison of HIV risk profiles among abductees and non-abductees. Comparisons in risk behaviour between young people who were abducted and those who were not will help inform appropriate and effective responses to HIV and other post-conflict  171 programming for all young people as they continue their transition from camp living back to their home villages.  6.2 Methods 6.2.1 Participants and procedures The study took place between May and December 2010 in Gulu District, northern Uganda. A cross-sectional survey design with blood specimen collection was used to determine HIV prevalence and gather information on socio-demographics, war-related experiences (including abduction and displacement), and sexual behaviour characteristics among 384 young people aged 15 to 29 years of age residing in a transit camp in 2 sub-counties in Gulu District. The two survey areas of the District ? Awach and Ongako sub-counties ? were chosen randomly from a list of all sub-counties in Gulu District that had transit camps at the time of data collection (18/23 sub-counties). The study population came from a total of 12 transit camps, which were selected purposively with the guidance of key informants in each sub-county, to reflect a range of remoteness/accessibility and resource availability.  A combination of proportional and non-proportional quota sampling was used, as random and systematic sampling methods were not feasible in the transit camps due to limited data on the population and the unsystematic lay-outs of the camps [Green & Browne, 2005; Kalton, 1983]. The sample size required to estimate the prevalence of HIV infection among young people residing in transit camps in Gulu District, northern Uganda - such that the error of estimation is within 3% of its actual parameter with 95% confidence - was calculated to be 384. In the calculation, HIV prevalence was estimated to be 10% after taking into account the following: regional HIV prevalence estimates from the Ugandan Sero- 172 Behavioural Survey of 8.2% among young people in northern Uganda [Ministry of Health, 2006]; the fact that Gulu District was one of the districts most impacted by conflict in northern Uganda [Dolan, 2009], and; the informed opinions of local researchers on the ground. Our resultant sample of 384 participants was further allocated in proportion to the population size of each sub-county. Additionally, a non-proportional quota of 50% of the sample was set with respect to the total number of male and female participants desired. The research team collaborated with hired community mobilizers in each site who assisted with our sampling process, ensuring that we met our predetermined sampling quotas. The sub-sample size of formerly abducted participants required to have adequate power (80%) to detect a meaningful difference in HIV prevalence between former abductees and non-abductees, if one were to occur, was calculated to be 105 participants. Using a two-tailed two sample test with percentage values, this calculation included: an alpha error level of 5%, and; estimations of sample prevalence based on the informed opinions of the research team (i.e., 17% for abductees and 7% for non-abductees). Out of the 384 participants in our study sample, 107 self-reported having experienced abduction. All participants met with a highly-trained, same-sex Acholi research assistant, blind to the HIV status of participants and bilingual in the local language of Luo and English, who confirmed study eligibility, explained procedures and sought informed consent, prior to the administration of the questionnaire. Informed consent was obtained from all young people and parental assent was also obtained for unemancipated minors aged 15 to 17 years. Following the interview, a trained nurse administered the INSTI HIV-1/HIV-2 Antibody Rapid HIV Test (Biolytical Laboratories) to participants. An additional sample of blood was collected from those testing positive with the rapid test and specimens were transported to the  173 CDC Laboratories at the Uganda Virus Research Institute (UVRI) in the city of Entebbe for confirmatory testing using two enzyme-linked immunosorbent assay (ELISA) tests (Abbott Murex HIV-1/2 ELISA, Murex Biotech Limited, United Kingdom and Vironostika HIV Uni-Form II MicroELISA, bioMerieux, Switzerland), and, if required, a Western Blot analysis (Calypte Biomedical) for definitive characterization.  Each interview, including specimen collection for HIV testing, took approximately 1.5-2 hours to complete. All interviews and testing took place in a private and quiet place of the participant?s choosing and were conducted anonymously with no names or personal identifiers recorded. Adhering to Ugandan testing guidelines, we actively encouraged all participants to receive their test results; however, only those participants opting for their results received them and receiving a result was not a requirement of participating in the study. As our survey questions dealt with sensitive and traumatic subjects, including sexual behaviour, sexual violence and war-related experiences, immediate referrals and psychosocial support were provided to participants who requested them; two outreach trauma counselors were hired and traveled with the team to the field daily. In addition, referrals were also made for follow-up HIV/AIDS care at the participant?s request and participants were referred to the St. Mary?s Hospital Lacor HIV clinic closest to their residence. As compensation for their time spent on the research and therefore away from their gardens and household activities, participants received remuneration of 4000 UG shillings each (approximately $2.00 USD). Ethical approval for the study was provided by the Ugandan National Council for Science and Technology, the Child Health and Development Centre at Makerere University in Kampala, Uganda and, the University of British Columbia, in  174 Vancouver, Canada. Approval was also granted from the Republic of Uganda, Office of the President. 6.2.2 Statistical analysis As the objective of this study was to determine the effect of abduction and living in the bush on prevalence of HIV and risky behaviours in comparison to HIV prevalence and risk profiles of young people who were not abducted, a descriptive/bivariate analysis without any multivariable modeling was deemed appropriate for fulfilling that objective. All analyses were conducted using SPSS Version 19.0. Point estimates of HIV prevalence and corresponding 95% confidence intervals were calculated separately for specified groups of interest, including: all participants together; participants who had been abducted by the LRA and those who had not, and; female and male abductees. Descriptive statistics (frequencies, proportions, medians and ranges) were obtained for characteristics of abduction for all abductees, as well as separately for male and female abductees. A series of bivariate analyses were then conducted (first among all participants and then stratified by gender), examining differences in socio-demographic characteristics; war-related experiences; sexual activity; survival/livelihood circumstances; HIV/AIDS prevention practices, and; health status information, among abductees and non-abductees. Categorical variables were compared using Pearson?s chi-square and Fisher?s exact test when 25% or more of the expected cell frequencies in a contingency table were less than 5. For continuous variables, the Wilcoxon rank sum test was used to compare medians of non-normally distributed variables. All reported p-values are two-sided.     175 6.3 Results 6.3.1 Sample characteristics Characteristics of the sample are provided in Table 6.1. An equal proportion of young women (50%) and young men (50%) were included in the sample. The median age of respondents was 20 years and the main ethnic group was Acholi (98%). Nearly 40% of participants were currently married and 25% were currently in school. Over half (58%) of respondents had been displaced for more than 10 years, and 68% had been living in a transit camp for 1-5 years. One hundred and seven (28%) respondents self-reported having experienced abduction.                 176 Table 6.1    Sample characteristics of participants (N=384) Characteristics Number (%) Number of young women 192 (50.0) Age, yr, median (range) 20 (15-29) Sub-county    Awach    Ongako  168 (43.8) 216 (56.2) Religion    Roman Catholic    Protestant Church of Uganda    Muslim    Pentecostal Christian  311 (81.0) 47 (12.2) 14 (3.7) 12 (3.1) Ethnicity    Acholi    Other  376 (97.9) 8 (2.1) Marital status    Currently married    Other    Never married  150 (39.0) 82 (21.4) 152 (39.6) School status    Ever school     In school    Dropped out  374 (97.4) 96 (25.0) 278 (72.4) Personal income based on previous month    <25,000 UGS*1    25,000-50,000 UGS    >50,000 UGS    Dependent on parents    Refused to answer  232 (60.4) 60 (15.6) 57 (14.8) 26 (6.8) 9 (2.3) Duration of displacement in camps    Never    3-5 years    5-10 years     More than 10 years    Since I was born  12 (3.1) 28 (7.3) 85 (22.1) 221 (57.6) 38 (9.9) Duration of stay in transit camp    1-6 months    7-12 months    13months- 2 years    3-5 years    More than 5 years  20 (5.2) 65 (16.9) 166 (43.2) 97 (25.3) 36 (9.4)  177 Characteristics Number (%) Ever abducted by the LRA    Yes    No  107 (27.9) 277 (72.1) *1 Approximately $12USD                       178 6.3.2 Characteristics of abduction Characteristics of abduction are presented in Table 6.2. Out of the 107 (28%) respondents who reported that they had been abducted at some point by the LRA, 42 (39%) were young women and 65 (61%) were young men. The median age at abduction was 13 years overall, 12 years among females and 14 years among males. Sixty-seven percent of former abductees reported that they were abducted from the IDP camp where they lived and 12% indicated that they had been abducted from a school building or school grounds (data not shown). Median length of time in captivity was 14 months, and the median number of years since return from the bush was 7.5, with males reporting a longer duration of abduction and therefore shorter length of time since return. The results on exposure to traumatic events while abducted are also presented in Table 6.2. While abducted, the vast majority of respondents (94%) reported living in difficult circumstances and indicated that they were made to carry heavy loads (94%). More than half of respondents (57%) were forced into military training and half (50%) were made to fight. Nearly three quarters (73%) were injured while in the bush and 77% were seriously beaten. Two-thirds of respondents were made to abduct other children (66%) and 70% looted properties and burned civilians? houses. One-fifth (20%) of formerly abducted young people were sexually abused while in the bush and only 4% of respondents indicated having access to condoms while abducted. A third (33%) of participants reported personally killing another person while over two-thirds (67%) had witnessed someone being killed. Over 40% of formerly abducted young women reported being given as a wife while in captivity and the median number of times given as a wife was 1. In addition, 12% of female abductees reported giving birth while in the bush. In contrast,  179 17% of formerly abducted young men indicated being given a wife while in captivity and median number of times they were given a wife was 1 time.  A comparison of experiences pertaining to exposure to traumatic events while in captivity demonstrated significant differences between young women and young men. A significantly higher proportion of formerly abducted young men compared to formerly abducted young women reported: looting properties and burning houses (82 vs. 52%, p=0.001); being made to abduct other children (79 vs. 48%, p=0.001); being forced into military training (68 vs. 41%, p=0.014), and; being made to fight (62 vs. 31%, p=0.005). While young women were significantly more likely to report being sexually abused while abducted (33 vs. 11%, p=0.004), we interestingly found no significant difference in the proportions of young men and young women who had personally killed someone while in captivity.               180 Table 6.2    Characteristics of formerly abducted participants  Variable Total No (%) n=107 Females No (%) n=42 Males No (%) n=65  p value Age of abduction, yr, median (range) 13 (6-21) 12 (6-19) 14 (7-21) 0.019 Length of time in captivity, months, median (range) 4 (.25-180) 3 (.25-180) 4 (.25-99) 0.870 Length of time since return from bush, years, median (range) 7.5 (.08-19) 10 (.08-17) 6 (.08-19) 0.001 While in the bush: made to carry heavy loads 100 (93.5) 41 (97.6) 59 (90.8) 0.242 was seriously beaten 82 (76.6) 31 (73.8) 51 (78.5) 0.579 was injured 78 (72.9) 33 (78.6) 45 (69.2) 0.288 witness someone being killed 72 (67.3) 29 (69.0) 43 (66.2) 0.755 personally kill another person 35 (32.7) 14 (33.3) 21 (32.3) 0.449 stayed in difficult circumstances 101 (94.4) 37 (88.1) 64 (98.5) 0.033 looted properties and burned houses 75 (70.1) 22 (52.4) 53 (81.5) 0.001 made to abduct other children 71 (66.4) 20 (47.6) 51 (78.5) 0.001 forced into military training 61 (57.0) 17 (40.5) 44 (67.7) 0.014 made to fight 53 (49.5) 13 (31.0) 40 (61.5) 0.005 was sexually abused 21 (19.6) 14 (33.3) 7 (10.8) 0.004 had access to condoms 4 (3.7) 3 (7.1) 1 (1.5) 0.297 gave birth   5 (11.9)   given as a wife # of times, median (range)  17 (40.5) 1 (1-3)   given a wife # of times, median (range)   11 (16.9) 1 (1-2)       181 6.3.3 Prevalence of HIV As seen in Table 6.3, 49 (12.8%) of the total 384 participants sampled tested positive for the HIV antibody (95% CI: 9.6%, 16.5%). Thirteen (12.1%) formerly abducted participants were HIV-positive compared with 36 (13.0%) participants who had never been abducted. Among young men, 8 (12.3%) formerly abducted participants were HIV-positive compared with 11 (8.7%) non-abducted participants. Among young women, 5 (11.9%) formerly abducted participants were HIV-positive compared with 25 (16.7%) non-abducted participants. No significant differences in proportions positive for HIV were demonstrated among formerly abducted and non-abducted participants overall or when stratified by gender.                   182 Table 6.3    Prevalence of HIV infection among study participants who were abducted and those who                       were not  All Participants Prevalence Estimate (%) [95% CI] (# Infected/Total N) 12.8 [9.6-16.5] (49/384)    Group Formerly Abducted Prevalence Estimate (%) [95% CI] (# Infected/Total N) Not Abducted Prevalence Estimate (%) [95% CI] (# Infected/Total N) p value All participants 12.1 [6.6-19.9] (13/107) 13.0 [9.3-17.5] (36/277) 0.824 Males 12.3 [5.4-22.8] (8/65) 8.7 [4.4-14.9] (11/127) 0.423 Females 11.9 [3.9-25.6] (5/42) 16.7 [11.1-23.6] (25/150) 0.453             183 6.3.4 Comparisons among abducted and non-abducted participants All bivariate comparisons between participants who had been abducted (n=107) and those who had not (n=277), stratified by gender, are summarized in Table 6.4, grouped into six categories of interest.  Demographics and background information Respondents who self-reported having experienced abduction were of older median age (23 vs. 19 years, p<0.001), and were more likely to have been married at some point (71% vs. 56%, p=0.008), in comparison to non-abducted participants. In addition, former abductees were less likely to be in school (15% vs. 29%, p=0.005). Among male participants, a significantly higher proportion of former abductees compared to non-abductees were resident of Awach sub-county (54% vs. 39%, p=0.044), and former male abductees were less likely to have been night-commuting during the war (66% vs. 83%, p=0.010). In contrast, former female abductees compared to non-abductees reported a significantly lower median age at first marriage (15 vs. 16 years, p=0.002). Sexual activity and practices Eighty-nine percent of former abductees reported having had sex, in comparison to 74% of non-abductees (p=0.002), with significantly greater proportions of sexually active abductees compared to non-abductees also observed by gender. Among those who reported ever having had sex, 67% of former abductees compared with 69% of non-abductees reported having had sex in the past 6 months (p=0.819) and there were no significant differences by gender. Former abductees reported a greater median number of sex partners in the previous 6 months (2 vs. 1, p=0.021) and this significant difference was also observed among former male abductees compared to non-abductees (2 vs. 1, p=0.055). With respect to  184 first sexual experience, female abductees reported a significantly lower median age at sexual debut (15 vs. 16 years, p=0.009) compared to non-abductees. Moreover, a significantly greater proportion of former abductees compared to non-abductees reported: non-consensual first-time sex (31% vs. 11%, p<0.001); that their first sex partner was 10 or more years older than they (26% vs. 13%, p<0.001), and; that the occupation of their first sex partner was military/rebel soldier (25% vs. 2%, p<0.001). All three of these significant associations were also demonstrated separately for male and female participants. A significantly greater proportion of formerly abducted participants reported having practiced dry sex (61% vs. 46%, p=0.018), and this significant difference was also demonstrated among male abductees when compared to non-abductees (64% vs. 44%, p=0.038). Among females, former abductees, when compared to non-abductees, were more likely to indicate currently having a sex partner besides their spouse (10% vs. 0%, p=0.013). Gender-based violence Among sexually experienced young people, a significantly greater proportion of former abductees than non-abductees reported ever having experienced physical/sexual/verbal abuse from any of their sexual partners (63% vs. 44%, p<0.001), and this was also the case for having experienced abuse in the previous 12 months (38% vs. 25%, p=0.012). These significant differences were also demonstrated separately for females and males. Similarly, when comparing formerly abducted participants to non-abducted participants, overall as well as separately by gender, a significantly greater proportion of former abductees indicated having been raped in the past (34% vs. 13%, p<0.001; Males: 20% vs. 3%, p=0.001; Females: 53% vs. 21%, p<0.001). We found no significant difference between former abductees and non-abductees with respect to the proportion of participants reporting that their  185 perpetrator at rape was 10 or more years older than they; however, a high proportion of respondents (60%) did indicate their perpetrator was 10 or more years older than they. Among sexually experienced young men, nearly 25% reported ever having beaten their partner and no difference between former abductees and non-abductees was demonstrated.  Survival/livelihood activities and food security When comparing survival/livelihood activities and food insufficiency measures between former abductees and non-abductees, both overall and by gender, no significant differences were demonstrated. Limited agricultural cultivation as a primary means of livelihood was reported by similar proportions of former abductees and non-abductees overall (p=0.242), as well as by gender, while participants who reported brewing alcohol as their primary means of livelihood were all female, with no significant difference demonstrated between female abductees and non-abductees (p=0.432). Similarly, the 11 participants who reported having exchanged sex for food, shelter, money or gifts (i.e., survival sex) were also all female, and no significant difference was demonstrated between female abductees and non-abductees (p=0.860). Food insufficiency was experienced by similar proportions of former abductees and non-abductees; 40% of former abductees and 40% of non abductees were currently experiencing a lack of food and/or water and 51% of former abductees compared to 55% of non-abductees indicated not having had enough food to eat in the previous 12 months.  HIV/AIDS prevention and condom use A significantly greater proportion of formerly abducted participants compared to non-abducted participants reported ever having used a condom (64% vs. 51%, p=0.022), although no significant differences by abduction status were demonstrated for condom use in the previous 6 months. Only 19% of sexually experienced young people indicated consistent  186 condom use and there were no significant differences by abduction status overall, or by gender. The vast majority of both former abductees (88%) and non-abductees (79%) had had at least one previous HIV test, and a significantly greater proportion of male abductees compared to male non-abductees reported ever having tested their blood for HIV (85% vs. 69%, p=0.021). Former abductees indicated a lower median number of HIV tests in lifetime in comparison to non-abductees; however, this difference was not significant (13 vs. 15 times, p=0.577). A significantly smaller proportion of formerly abducted participants had knowledge of their partner?s HIV status compared to participants who had not been abducted (65% vs. 87%, p<0.001). This significant difference in proportions of those who had knowledge of their partner?s HIV status was also demonstrated among male abductees compared to male non-abductees (78% vs. 93%, p=0.017).  Health status and service utilization One-third of participants reported never having sought healthcare outside of their home and there were no significant differences demonstrated by abduction status. Similarly, 58% of respondents indicated having had a health problem in the previous 12 months (73% reported the health problem to be malaria), with no significant difference demonstrated by abduction status. In contrast, a significantly higher proportion of formerly abducted participants than non-abductees had experienced ill health without medical care in the previous 3 months (20% vs. 8%, p<0.001) and this difference was also demonstrated among female abductees compared to non-abductees (19% vs. 6%, p<0.014). No significant differences were demonstrated between proportions of former abductees and non-abductees who perceived that they were very likely to have been exposed to HIV, who reported ever having imbibed alcohol, and who indicated ever having had a STI besides HIV. Among  187 sexually experienced young women, a significantly higher proportion of former abductees compared to non-abductees reported having had STI symptoms in the previous 12 months (53% vs. 28%, p=0.011), and 87% reported past pregnancies, with no significant difference demonstrated between formerly abducted young women and female non-abductees. Six percent of young men reported having been circumcised. Comparisons by abduction status among those circumcised showed no significant proportional difference.    188 Table 6.4    Comparison of socio-demographic and behavioural characteristics of formerly abducted and non-abducted participants stratified by gender                                             Male                      Female                        Total  Formerly Abducted (N=65) Not Abducted (N=127)   Formerly Abducted (N=42) Not  Abducted (N=150)   Formerly Abducted (N=107) Not  Abducted (N=277)                  Variable N (%) N (%) p value  N (%) N (%) p value     N (%) N (%) p value Demographics & Background Information Age, yr, median (range) 22 (15-29) 19 (15-29) 0.015  23 (15-29) 19 (15-29) 0.004  23 (15-29) 19 (15-29) <0.001 Awach sub-county 35 (53.8) 49 (38.6) 0.044  19 (45.2) 65 (43.3) 0.826  54 (50.5) 114 (41.2) 0.099 Ever married 40 (61.5) 52 (40.9) 0.007  36 (85.7) 104 (69.3) 0.035  76 (71.0) 156 (56.3) 0.008 Age at 1st marriage, yr, median (range) 18 (12-24) 18 (12-25) 0.099  15 (9-22) 16 (13-22) 0.002  16 (9-24) 17 (12-25) 0.118 In school 13 (20.0) 43 (33.9) 0.046  3 (7.1) 37 (24.7) 0.013  16 (15.0) 80 (28.9) 0.005 Duration of displacement more than 10 years 39 (60.0) 68 (53.5) 0.394  31 (73.8) 121 (80.7) 0.333  70 (65.4) 189 (68.2) 0.598 Living arrangements ? All the family 11 (16.9) 24 (18.9) 0.514  14 (33.3) 47 (31.3) 0.598  25 (23.4) 71 (25.6) 0.800 Monthly income based on previous month < 25,000 UGS 34 (52.3) 66 (52.0) 0.685  33 (78.6) 99 (66.0) 0.117  67 (62.6) 165 (59.6) 0.380 Night commuter*1 43 (66.2) 105 (82.7) 0.010  33 (78.6) 97 (64.7) 0.088  76 (71.0) 202 (72.9) 0.709 Sexual Activity/Practices & Relationships Sexually active 55 (84.6) 90 (70.9) 0.036  40 (95.2) 116 (77.3) 0.009  95 (88.8) 206 (74.4) 0.002 Age at first sex, yr, median (range) 17 (9-24) 17 (8-25) 0.995  15 (6-18) 16 (8-22) 0.009  16 (6-24) 16 (8-25) 0.224 Condom used 1st sexa 19 (34.5) 39 (43.3) 0.125  11 (27.5) 44 (37.9) 0.125  30 (31.6) 83 (40.3) 0.710 Non-consensual 1st sexa 9 (16.4) 2 (2.2) 0.001  20 (50.0) 21 (18.1) <0.001  29 (30.5) 23 (11.2) <0.001  189                        Male                      Female                        Total  Formerly Abducted (N=65) Not Abducted (N=127)   Formerly Abducted (N=42) Not  Abducted (N=150)   Formerly Abducted (N=107) Not  Abducted (N=277)                  Variable N (%) N (%) p value  N (%) N (%) p value     N (%) N (%) p value 1st sex partner 10 or more years oldera 4 (7.3) 2 (2.2) 0.008  21 (52.5) 24 (20.7) <0.001  25 (26.3) 26 (12.6) <0.001 Occupation of 1st sex partner military/rebela 7 (12.7) 0 (0) <0.001  17 (42.5) 3 (2.6) <0.001  24 (25.3) 3 (1.5) <0.001 Had sex past 12 months 47 (85.5) 72 (80.0) 0.406  24 (60.0) 91 (78.4) 0.022  71 (74.7) 163 (79.1) 0.480 Had sex past 6 months 44 (80.0) 71 (78.9) 0.873  20 (50.0) 72 (62.1) 0.250  64 (67.3) 143 (69.4) 0.819 Currently have sex partner besides your spouse 6 (19.4) 9 (23.1) 0.873  2 (10.0) 0 (0.0) 0.013  8 (15.7) 9 (9.1) 0.219 Condom use last sexa 23 (41.8) 32 (35.6) 0.451  8 (20.0) 23 (19.8) 0.981  31 (32.6) 55 (26.7) 0.290 Imbibed alcohol last sexa 2 (3.6) 1 (1.1) 0.557  4 (10.0) 8 (6.9) 0.506  6 (6.3) 9 (4.4) 0.570 No. of sex partners past 6 months, median (range) 2 (1-9) 1(1-5) 0.055  1 (1-2) 1 (1-2) 0.621  2 (1-9) 1 (1-5) 0.021 Had sex partner from outside community in past 6 monthsb 8 (18.1) 7 (9.9) 0.097  2 (10.0) 9 (12.5) 0.897  10 (15.6) 16 (5.8) 0.212 Ever practice dry sex*2, a 35 (63.6) 40 (44.4) 0.038  23 (57.5) 54 (46.6) 0.312  58 (61.1) 94 (45.6) 0.018 Discuss sex with anyone 45 (69.2) 82 (64.6) 0.518  21 (50.0) 71 (47.3) 0.760  66 (61.7) 153 (55.2) 0.253 Gender-based Violence Ever experience physical/sexual/verbal abuse from sexual partner(s)a 28 (50.9) 26 (28.9) 0.001  32 (80.0) 64 (55.2) <0.001  60 (63.2) 90 (43.7) <0.001 Experience abuse past 12 monthsc 16 (34.0) 14 (19.4) 0.014  11 (45.8) 26 (28.6) 0.050  27 (38.0) 40 (24.5) 0.012  190                        Male                      Female                        Total  Formerly Abducted (N=65) Not Abducted (N=127)   Formerly Abducted (N=42) Not  Abducted (N=150)   Formerly Abducted (N=107) Not  Abducted (N=277)                  Variable N (%) N (%) p value  N (%) N (%) p value     N (%) N (%) p value Ever been rapeda 11 (20.0) 3 (3.3) 0.001  21 (52.5) 24 (20.7) <0.001  32 (33.7) 27 (13.1) <0.001 Age at rape, yr, median (range) 17 (12-24) 16 (11-19) 0.607  14 (6-19) 14 (8-23) 0.595  14 (6-24) 14 (8-23) 0.992 Perpetrator 10 or more years older 4 (36.4) 3 (100.0) 0.192  15 (71.4) 13 (54.2) 0.378  19 (59.4) 16 (59.3) 1.000 Ever beat sexual partnera 13 (23.6) 22 (24.4) 1.000      13 (13.7) 22 (10.7) 0.566 Survival/Livelihood Activities & Food Security Main means of livelihood ?Limited cultivation 51 (78.5) 99 (78.0) 0.875  30 (71.4) 91 (60.7) 0.150  81 (75.7) 190 (68.6) 0.242 Main means of livelihood ?Brew alcohol     1 (2.4) 11 (7.3) 0.432  1 (.9) 11 (4.0) 0.216 Ever survival sex work*3a     2 (5.0) 9 (7.8) 0.860  2 (2.1) 9 (4.4) 0.539 Currently experience lack of food and/or water 17 (26.2) 26 (20.5) 0.372  26 (61.9) 84 (56.0) 0.494  43 (40.2) 110 (39.7) 0.932 Didn?t have enough food to eat past 12 months 28 (43.1) 61 (48.0) 0.515  27 (64.3) 91 (59.0) 0.541  55 (51.4) 152 (54.9) 0.670 HIV/AIDS Prevention & Condom Use Can protect yourself from HIV/AIDS 62 (95.4) 115 (90.6) 0.238  31 (73.8) 112 (74.7) 0.910  93 (86.9) 227 (81.9) 0.242 Able to say no to sex if you do not like it 65 (100.0) 126 (99.2) 1.000  28 (66.7) 115 (76.7) 0.189  93 (86.9) 241 (87.0) 0.982 Ever used a condom 49 (75.4) 79 (62.2) 0.067  19 (45.2) 61 (40.7) 0.595  68 (63.6) 140 (50.5) 0.022 Consistent condom use 17 (34.7) 24 (30.4) 0.769  1 (5.3) 14 (23.0) 0.085  18 (26.5) 38 (27.1) 0.903  191                        Male                      Female                        Total  Formerly Abducted (N=65) Not Abducted (N=127)   Formerly Abducted (N=42) Not  Abducted (N=150)   Formerly Abducted (N=107) Not  Abducted (N=277)                  Variable N (%) N (%) p value  N (%) N (%) p value     N (%) N (%) p value Condom use past 6 months 20 (40.8) 31 (39.2) 0.851  6 (31.6) 21 (34.4) 0.693  26 (38.2) 56 (40.0) 0.842 Ever HIV test 55 (84.6) 88 (69.3) 0.021  39 (92.9) 132 (88.0) 0.576  94 (87.9) 220 (79.4) 0.071 No. of HIV tests, median (range) 11 (0-27) 10 (0-30) 0.367  15 (0-23) 15 (0-25) 0.529  13 (0-27) 15 (0-30) 0.577 Know partner?s statusa 43 (78.2) 84 (93.3) 0.017  29 (72.5) 86 (74.1) 0.991  62 (65.3) 180 (87.4) <0.001 Health Status & Service Utilization Never sought healthcare outside of home 19 (29.2) 46 (36.2) 0.138  9 (21.4) 52 (34.7) 0.148  28 (26.2) 98 (35.4) 0.085 Had a health problem in past 12 months 31 (47.7) 49 (38.6) 0.226  33 (78.6) 110 (73.3) 0.491  64 (59.8) 159 (57.4) 0.668 Experienced ill health without medical care in past 3 months 13 (20.0) 13 (10.2) 0.104  8 (19.0) 9 (6.0) 0.014  21 (19.6) 22 (7.9) 0.001 Very likely to have been exposed to HIV 9 (13.8) 5 (3.9) 0.091  7 (16.7) 28 (18.7) 0.631  16 (15.0) 33 (11.9) 0.631 Ever imbibed alcohol 18 (27.7) 33 (26.0) 0.800  2 (4.8) 5 (3.3) 0.649  20 (18.7) 38 (13.7) 0.222 Ever imbibed alcohol before sex 7 (38.9) 18 (54.5) 0.242  1 (50.0) 3 (60.0) 1.000  8 (40.0) 21 (55.3) 0.241 Ever had STI besides HIVa 9 (16.4) 9 (10.0) 0.384  6 (15.0) 11 (9.5) 0.489  15 (15.8) 20 (9.7) 0.185 Had any STI symptoms past 12 monthsa 3 (5.5) 6 (6.7) 1.000  21 (52.5) 33 (28.4) 0.011  24 (25.3) 39 (18.9) 0.271 Ever circumcised  4 (6.2) 7 (5.5) 1.000          192                        Male                      Female                        Total  Formerly Abducted (N=65) Not Abducted (N=127)   Formerly Abducted (N=42) Not  Abducted (N=150)   Formerly Abducted (N=107) Not  Abducted (N=277)                  Variable N (%) N (%) p value  N (%) N (%) p value     N (%) N (%) p value Age of circumcision, yr, median (range) 13 (0-18) 12 (0-24) 0.847         Ever pregnanta     36 (90.0) 99 (85.3) 0.654     Age at first pregnancy, yr, median (range)     16 (10-20) 17 (13-22) 0.105     *1 Leaving your family hut at night to sleep elsewhere due to security and privacy concerns *2 Sexual intercourse without foreplay or lubrication so that the vagina is dry upon penetration *3 Exchanging sex for food, shelter, money, gifts  a  Among those reporting ever having had sex, Abducted males (n=55) Non-abducted males (n=90); Abducted females (n=40) Non-Abducted females (n=116)  b  Among those reporting sexual activity in the previous 6 months, Abducted males (n=44) Non-abducted males (n=71); Abducted females (n=20) Non-abducted females (n=72)  c Among those reporting sex partner in previous 12 months, Abducted males (n=47) Non-abducted males (n=72); Abducted females (n=24) Non-abducted females (n=91)  193 6.4 Discussion In this study, which investigated the effect of abduction on HIV prevalence and risk behaviours among former abductees in Gulu District, northern Uganda, and compared abductees? risk profiles with non-abductees? risk profiles, 28% of respondents self-reported having experienced abduction, of whom 61% were young men and 39% were young women. Length of abduction ranged from one week to 15 years, with 56% having been captive for at least four months, 35% in captivity for a year or more, and only 4% having been captive for more than five years. We also found, as have other studies on former child soldiers in northern Uganda [Blattman & Annan, 2008; Pham et al., 2009; SWAY, 2007], that LRA rebels force young abductees, both male and female, to commit violent acts such as killing civilians and looting properties and burning houses, possibly as an indoctrination ritual [Human Rights Watch, 2005a; De Temmerman, 2001]. These practices may force the abductee to violate their own moral principles and to break from any form of social attachment, ultimately making them more submissive and compliant to leadership [Amone-P?Olak, 2007].  In this study it was demonstrated that the proportion of former abductees identified as HIV-positive (12.1%) was not statistically different than the proportion of non-abductees identified as HIV-positive (13.0%), contrary to what was initially hypothesized and what NGO reports and media stories would lead one to believe [Annan et al., 2009]. In contrast, this study did produce some evidence to support a secondary hypothesis that young people who have experienced abduction and lived in the bush will exhibit greater risk behaviour than young people who were never abducted. Specifically, when comparing participants who had not been abducted with formerly abducted participants we found that the latter were  194 more likely to report a greater median number of sex partners in the previous 6 months, and were less likely to have knowledge of their sexual partner?s HIV status. Both of these significant associations were also observed among former male abductees compared to male non-abductees. Furthermore, in comparisons among female participants, former abductees were more likely than non-abductees to indicate currently having a sex partner besides their spouse and more likely to report having had STI symptoms in the previous 12 months. All of these significant findings illustrate elevated risk behaviour among formerly abducted young people within the previous 12 months.  Based on what we know from our previous research in northern Uganda as well as other studies focused on the experiences of former child soldiers in the region [Spittal et al., 2008; Patel et al., 2011; Annan et al., 2009; SWAY, 2007; Mazurana & McKay, 2004], prior to Operation Iron Fist, it was reported that girls who were abducted were not violated on their way to Sudan. If a girl was raped, her perpetrator was killed. Upon reaching the Sudan, the girls were delegated to a man, starting with the highest ranks [Annan et al., 2009]. Among the Acholi, the sign of maturity for any girl was the onset of menstruation [Ominde, 1952]. Abducted young girls who had had their first menstruation immediately became ?wives? and those who had not were kept as house helpers (ting-ting), until they started menstruating (keeping guard). A girl was not allowed to choose; it was the commander who assigned the girl a ?husband?. If a girl were found having sex with a man other than her ?husband?, she would be court-martialed and killed by a firing squad. Each girl remained with the man assigned to her until he died. Upon his death the decision about where his ?wife? went next was up to the higher commands. The girls described these experiences as ?sexual slavery? because there was no love, no consent and no bride wealth paid to their parents [Spittal et al.,  195 2008]. However, a report by SWAY [2008] points out that female abductees also performed vital combat and support roles within the LRA and most were not primarily used as ?sexual slaves?. Girls were sexually abused in captivity but almost exclusively within the confines of a ?forced marriage? to a rebel commander and rape outside of these forced marriages was rare [Annan et al., 2009]. Park [2006] notes that many forced wives described their relationship with a commander as a protective factor in the armed group, as they were given food and protected from sexual abuse from multiple men. Yet upon return from the bush, many of these young women experienced stigma associated with the community?s perceptions of their sexual enslavement. Early reports by the media and by NGOs constructed the sexual lives of returnees as ?free for alls?; young females were shared indiscriminately amongst rebel commanders [Spittal et al., 2008; Annan et al., 2009]. However, in reality, girls were given out to a household as house helpers (?ting-ting?) if they were of pre-menstruation age and to one man if they were older. In fact, a girl who was never abducted may have had more sexual partners than an abducted girl who had returned from the bush. In this study, the median number of times that female abductees reported being given as a wife was one and the median number of times that male abductees were given a wife was also one.  Based on the recounts of formerly abducted young women, coupled with reports indicating that rebels were reticent to abduct older children because they were worried that they might already be infected with HIV, [Spittal et al., 2008; Allen, 2006a; Annan et al., 2009; Beber & Blattman, 2009] and our study findings, we can make the assumption that young people were likely to be HIV-negative when abducted and possibly even HIV-negative when coming out of captivity, but contracted the virus after returning home. Literature does suggest that experiencing trauma in childhood may increase the likelihood of  196 subsequently engaging in high-risk sexual behaviour, thus increasing the risk of contracting HIV or other STIs [Koenig et al., 2003; Stewart et al., 1996; Handwerker, 1993; Maman et al., 2000]. In this study, 70% of formerly abducted participants had looted properties and burned houses; 33% of female abductees and 32% of male abductees reported personally killing another person; 66% of former abductees were made to abduct other children and 50% were made to fight, and; 33% of formerly abducted young women and 11% of male abductees reported being sexually abused while in captivity. These are all extremely traumatic events. Our study findings, which demonstrate no significant difference in HIV prevalence between former abductees and non-abductees and indicate an increase in risk behaviour among former abductees after they have left the bush and returned home to IDP camp living, reinforce the need for comprehensive post-conflict prevention programming for all war-affected young people, regardless of abduction status. Assistance to formerly abducted young people in northern Uganda has taken two main forms: reinsertion assistance and longer-term reintegration and development services. The primary instruments of reinsertion have been interim care (reception centres), Amnesty, and reinsertion packages, all of which are targeted directly at former abductees who report to a reception centre or to the Amnesty Commission [SWAY, 2007; Blattman & Annan, 2008]. The focus of the interim care and reception process has included access to basic health services, basic counseling, family tracing and reunification, and broad-based community sensitization measures. Most former abductees stay for two to six weeks at the centres, which offer very limited follow-up care and only occasional assistance for education, health, vocational training, food, or shelter [Pham et al., 2009], although findings from Phase II of the Survey of War-Affected Youth [2007] indicate that the most pressing needs for former  197 combatants are education and livelihoods support. Similarly, in this study we found that former abductees were significantly less likely to be in school, compared to non-abductees, and this disparity was most pronounced among female participants; over three times the proportion of non-abducted young women were in school compared to female respondents who reported experiencing abduction. Abducted young people miss out on their schooling largely due to their time away. The impact is greatest among long-term abductees, who attain one to two fewer grades on average than non-abducted young people and are more than twice as likely to be illiterate [SWAY, 2007; Blattman & Annan, 2008; Annan et al., 2006]. The education of women who return from the LRA with children is even more severely affected; unlike other abductees, these young mothers almost never go back to school upon return, in large part because of child care responsibilities [SWAY, 2008; Annan et al., 2009]. In a broad sense, education, both traditional and alternative, supports the reintegration of former child soldiers in a number of ways [Betancourt et al., 2008]. For example, Machel [1996] emphasizes the important link between literacy and skills learning and economic security for returning child soldiers, factors that often determine the successful social reintegration of returning children and prevent re-recruitment. Indeed, in northern Uganda, due to time away from school as well as serious injuries suffered during the war, former abductees were, on average, less than half as likely to be engaged in skilled work, and had a third lower daily earnings [Blattman & Annan, 2008]. Furthermore, Betancourt et al. [2008] points out that, perhaps most importantly, school attendance can help young people returning to their communities after abduction begin to see themselves as someone other than soldiers or victims. Educational programs may help to ?normalize? life for returning child soldiers and allow them to develop an identity and a sense of self-worth separate from that of a soldier  198 [Machel, 1996; Peters & Richards, 1998; Nicolai & Triplehorn, 2003; Betancourt, 2005; Williamson, 2005; Wessells, 2006a]. Much of the government and NGO reintegration focus in northern Uganda has been upon the primary school system and vocational training programmes, while ?best-practice? programmes including secondary school scholarships, accelerated adult education, child-care and school feeding for the children of students are extremely rare and serve only a small fraction of the under-educated population, including former abductees [Blattman & Annan, 2008]. Our study findings indicate an urgent need for the scaling-up of these best-practice programmes, so that more young people have access to appropriate educational opportunities post-conflict. Moreover, our findings are indicative of the foci of reintegration programming for former abductees, given that the most extensive impact of abduction appears to have been upon education [SWAY, 2007; Annan et al., 2009; Verhey, 2001]. In the medium to long term, it is suggested that true reintegration depends on former child soldiers having access to educational and training opportunities that will support them to achieve greater self-sufficiency and increased productivity within their communities [Betancourt et al., 2008]. In this study, it is important to note that although 97% of young people reported having been in school at some point, 74% subsequently dropped out. Lack of money for fees and school materials (i.e., uniforms, books, pencils), being too old to rejoin after substantial time away, and pregnancy were the main reasons given for dropping out of school. It is not surprising that the war interrupted education for not only former abductees but also for young people who did not experience abduction. The benefits of education for all war-affected young people are well-documented [Patel, 2006; De Walque, 2004; Human Rights Watch, 2005b; Kasente, 2003; Santacruz & Arana, 2002; Annan et al., 2006; Wessells, 2006b;  199 Sommers, 2003; Betancourt, 2005]. During the resettlement process in northern Uganda, it is critical for post-conflict programme planners: to focus efforts on increasing school enrollment of all war-affected young people; to provide realistic options to get young people back in school after substantial time away, and; to develop strategies to retain children who are already in school.  Since 2006, the Amnesty Commission has retroactively paid out reinsertion packages to former abductees who are holders of an Amnesty Certificate. Eligibility criteria for an Amnesty Certificate stipulate that bearers must be Ugandan citizens, aged 12 years or older at time of return, and must have fought against the Government of Uganda. The package includes household items, agricultural tools, seeds, and an unconditional cash payment, all items intended to help former abductees re-establish livelihoods [Pham et al., 2009; Blattman & Annan, 2008]. In this study, when comparing survival/livelihood activities and food insufficiency measures between former abductees and non-abductees, both overall and by gender, no significant differences were demonstrated. Rather, similar proportions of young people indicated limited agricultural cultivation as their main means of livelihood, and food insufficiency - also reported by similar proportions of abducted and non-abducted participants - was actually quite high overall (40% of respondents indicated a current lack of food and/or water, while 54% reported not having had enough food to eat in the previous 12 months). In addition, similarly high proportions of abductees and non-abductees indicated a monthly income of less than 25,000 UGS (63% vs. 60%, p=0.380). Based on these findings it seems unfair and even counter-productive that only formerly abducted young people are eligible for assistance with re-establishing livelihoods by means of the Amnesty Commission?s re-insertion packages, when it is clear that the impacts of the war have been  200 shouldered by everyone, regardless of abduction status. It is not the case that young people who did not experience abduction are devoid of any livelihood support, but aid agencies and government and NGO programmes may target formerly abducted persons disproportionately [Spittal et al., 2008; SWAY, 2007; Blattman & Annan, 2008]. Findings from the SWAY report [2007] suggest that the additional assistance to former abductees continues to upset and offend many community members and that the resultant unintended consequence of such an approach to service delivery may be stigmatization rather than reintegration. Having been through a reception centre or being eligible for an Amnesty Certificate is too crude a targeting measure to identify the most vulnerable returnees and never-abducted young people, and adequately address what these young people need. Designing programming for young people according to well-identified needs rather than abduction status may be less stigmatizing and more effective and would still reach the most vulnerable by default. Moreover, moving from a system of circumstantial categorization to one based on specific, easily identified, and acute needs promises more effective re-insertion assistance for formerly abducted young people.  Based on findings from this study one of those specific needs appears to be increased support for victims of sexual violence upon their return home, not only for young women but also for young men. The majority of research on sexual violence and HIV infection in times of conflict focuses on women and girls. However, there are many anecdotal accounts that suggest that during high intensity conflicts boys and men are as susceptible to sexual violence as women are [USAID, 2000]. Closed environments, such as IDP camps or rebels? barracks, are potentially conducive to male/male rape or other non-consensual sexual penetration [Hankins et al., 2002]. Moreover, unprotected anal intercourse is a more effective  201 means of HIV transmission than most other forms of sexual activity [Baggaley et al., 2010; Grulich & Zablotska, 2010]. In this study, 11% of formerly abducted young men reported being sexually abused while in captivity, 16% reported non-consensual sexual debut, 51% of sexually experienced male abductees indicated having been abused by a sexual partner (with 34% indicating abuse in the previous 12 months), and 20% reported having been raped. Out of the 11 cases of reported rape, 9 (82%) occurred at sexual debut. Furthermore, male abductees, in comparison to non-abductees, were significantly more likely to have experienced all of the sexually violent events listed above. With respect to young men?s first sexual experience, out of the 9 former abductees who indicated non-consensual sexual debut, 4 (44%) reported that their first sex partner was 10 or more years older than they, and 7 (78%) reported the occupation of their first sex partner to be military/rebel soldier (who was most likely of the male gender, given the gendered hierarchy of military/rebel groups). In fact, 7 male participants in our sample overall indicated that the occupation of their first sex partner was military/rebel soldier and all of these 7 young men were former abductees. In a cross-sectional study it is difficult to determine with certainty that all experiences of sexual violence reported by young men in this study occurred while abducted. Our findings underscore the importance of conducting further research to better understand the impact of conflict on abducted males? susceptibility to sexual violence during captivity. In the meantime, however, reintegration programmes for former abductees and post-conflict prevention programmes for young people that address sexual violence must recognize that males can also be victims and therefore must be included in programming responses that are sensitive to their needs and their experiences of rape.  202 This study has several limitations. Attaining a probabilistic sample was a challenge with this population. Therefore, the results cannot be generalized to all young people across northern Uganda and only represent the youth population from which we sampled. However, given that over 90% of the population of northern Uganda was encamped during the war and Gulu District was the most heavily impacted District in the region, we are confident that our sample including residents from 2 sub-counties in the District is representative of conflict-affected young people living in Gulu District. Another limitation lies within the design of the study. Given the cross-sectional nature of this study, we cannot determine if certain experiences known to elevate risk, such as rape, preceded or followed abduction. The associations between abduction status and risk factors do not inform us of their relative temporal sequence. Prospective studies, which follow young people before and after abduction, are required to make causal inferences in this regard. The study relies on self-reported data that may have been affected by social desirability and recall errors. To minimize this, all participants were interviewed by a research assistant of the same gender, we extensively trained our Acholi interviewers, and we used a consent form stressing the confidential and anonymous nature of the interviews. These approaches have been shown to minimize response bias and maximize reliability among respondents [De Irala et al., 1996]. Finally, we analyzed abductees as a group, not taking into account length of time in captivity. This may mean that the implications of our study findings, including the identification of specific programming needs, may not be applicable to all young people who have experienced abduction. However, findings from a large-scale survey including 462 formerly abducted young people in northern Uganda demonstrate that extremely long-term abductions  203 do not consistently predict poor well-being or identify specific vulnerabilities [SWAY, 2007]. The findings presented in this paper demonstrated that all young people are struggling and suffering due to the war and prolonged displacement. Moreover, our findings suggest that designing programmes with only formerly abducted young people in mind is likely to be unsuccessful in reducing vulnerability, in addressing needs, and in improving long-term reintegration. The main reason is that abduction status may be a rudimentary and unreliable predictor of need. Large numbers of non-abducted young people exhibit serious educational, economic, social, and health challenges, while at the same time, significant numbers of abductees perform quite well relative to their peers [SWAY, 2007]. A near exclusive focus on returnees leaves out many thousands of never-abducted young people who have suffered terrible consequences due to the war. Therefore, targeting based primarily on abduction does not typically capture the most vulnerable and underprivileged young people and also fails to address young peoples? needs. Similarly, a one-size-fits-all approach to services for formerly abducted young people does little to meet the actual needs of returnees, given the heterogeneity of abduction?s impacts. Designing programmes based on abduction experience also carries the risk of stigmatization and may offend and lead to increased resentment from community members [Blattman & Annan, 2008]. Indeed, it does seem unfair that former abductees, including former LRA commanders who themselves are responsible for gross violations of human rights experienced by hundreds of thousands of civilians, benefit from distinct services while those who are ?merely? victims are left with nothing. Programmes that target based on specific and identifiable needs ? education, livelihood development, sexual violence support ? are likely to be less stigmatizing as well as more inclusive, self-selecting,  204 and effective than those based on abduction status. It has been suggested that beyond basic reinsertion support, abduction status should not be a special category, determinant or precondition of aid [Blattman & Annan, 2008]. Rather, in post-conflict northern Uganda the aim should be to move from adhoc to evidence-based policy, with programmes targeted to young people with the most serious educational, economic, psychosocial, and health challenges.                   205 Chapter  7: Recommendations and Conclusions 7.1 Summary of Study Findings The current study investigated HIV prevalence and related vulnerabilities among war-affected young men and women residing in transit camps in Gulu District, northern Uganda. The research findings provide valuable insights into understanding the war-related experiences of young people, and also demonstrate how conflict can influence HIV transmission dynamics and prevention. Moreover, this study identified specific needs of young people surviving abduction and displacement and provided critical information for designing responses to HIV in a post-conflict setting. Study findings provide evidence of limited differences in HIV prevalence by gender and abduction status and demonstrate that all young people have been adversely affected by the war. It is therefore necessary that post-conflict HIV prevention and care planners develop interventions based on specific, easily identified, and acute needs of young people as an alternative to current programming based on circumstantial categorization (i.e., abduction status).  The analysis presented in Chapter 4 identified an overall prevalence rate of 12.8% and found seven factors to be independently associated with increased risk of HIV infection. The strongest predictor of HIV infection among young people was non-consensual sexual debut; participants who reported that their first sexual experience was forced were nearly 10 times more likely to be HIV-positive than participants whose sexual debut was consensual. Subsequent separate multivariate modeling by gender in Chapter 5 suggested that this effect of non-consensual sexual debut was restricted to males. This makes biologic sense because unprotected anal intercourse is a more effective means of HIV transmission than most other forms of sexual activity [Baggaley et al., 2010; Grulich & Zablotska, 2010].  206 Our analyses also identified a relationship between the practice of dry sex and an elevated risk of HIV infection, which has never been established in Uganda before. Participants who reported having practiced dry sex were 2.3 times more likely to be HIV-positive than respondents who had never practiced dry sex. Subsequent analyses in Chapter 5 demonstrated that dry sex was a strong risk factor in females with an adjusted odds ratio of 7.6, but not in males. The elevated risk of HIV infection associated with the practice of dry sex in young women may be mediated by vaginal trauma as lack of lubrication during penetration increases the likelihood of lacerations in the vaginal wall, creating an environment susceptible to infection [Hyena, 1999]. The potent effect of dry sex in young women might partially explain the higher HIV prevalence among females (15.6%) compared to males (9.9%), though this difference in prevalence did not reach conventional statistical significance.  Furthermore, two protective factors for HIV infection were identified among young people in our analyses in Chapter 4: Respondents who perceived that they could protect themselves from HIV were 71 percent less likely to be HIV-positive, and; for every one-unit increase in HIV tests taken in lifetime, the probability of HIV infection decreased by 14%. Subsequent multivariate modeling by gender in Chapter 5 suggested that the effect of both of these protective factors also applied separately to male and females. It is difficult to determine whether the protective effect of testing for HIV can be explained through effective counseling and testing services or alternatively whether the effect is a result of positive cases ceasing to re-test after acquiring knowledge of their status, while negative cases continue to test. More research is needed to better understand the mechanisms involved in the relationship between number of HIV tests taken over lifetime and HIV infection.   207 Finally, we found no evidence in our analyses in Chapters 4 and 5 that a history of abduction by the LRA was a risk factor for HIV infection. Additionally, in analyses presented in Chapter 6, comparing HIV prevalence and related vulnerabilities among former abductees and non-abductees, no statistically significant difference between the prevalence rate of 12.1% among abductees and 13% among non-abductees was demonstrated. These findings are particularly interesting as they stand in stark contrast to what NGO reports and media stories would lead one to believe [Annan et al., 2009]. Moreover, in Chapter 6 analyses, it was established that abducted and non-abducted young people are almost equally vulnerable to HIV infection and that the levels of access to health, education, income and employment for all young people in the war-affected North are dreadful. All young people face tremendous difficulties with schooling, both in terms of access and retention. Many young people ? abducted or not ? are experiencing food insufficiency. Employment levels for all young men and women are abysmally low and yield meager incomes. Also of note is that an unacceptable number of young women and young men have experienced significant sexual violence, regardless of whether they were abducted or not. Our analyses illustrated that abduction in itself is a poor predictor of vulnerability. Therefore, reinsertion packages and other forms of NGO assistance offered exclusively to former abductees do not necessarily target the most vulnerable and underprivileged young people but rather leave out many thousands of young people who did not experience abduction yet are suffering terrible repercussions due to the war.      208 7.2 Study Strengths and Unique Contributions 7.2.1 Strengths The candidate ran and funded this study independent of any ties to a larger research project. She conceived the research questions; developed her own tools and protocols; recruited, trained, supervised and managed a team of researchers; coordinated all study activities in the field; completed data entry, and; conducted all statistical analyses. This primary research permitted the progression from formulating a research question to designing methods to answer that question, enabling the candidate to address specific research issues. Moreover, having control over data collection meant that important variables of interest, type of sample and other design issues were considered [Polit & Hungler, 1995].  An additional strength of the study?s research relates to the HIV testing protocol it employed. All samples testing positive with the rapid HIV test underwent confirmatory testing using two ELISA tests and, if required, a Western Blot analysis for definitive characterization. Study participants, as well as local health professionals with whom we liaised, expressed their gratitude for having test results confirmed to ensure a true HIV status had been received. This proved to be particularly beneficial for two study participants who at the time of interview disclosed that they were HIV-positive and on treatment medication (one participant had been on ARVs for 3 years and the other for 10 months). However, both their rapid and confirmatory test results indicated they were in fact HIV-negative, undoubtedly changing their lives for the better.  This study?s strength also derived from its research team, without whom it would not have been possible. The team was compromised of 15 members, all of whom were Acholi, had worked extensively in the region before, and understood the complexities of working  209 with war-affected populations. We purposely hired both male and female research assistants so that all study participants would have the additional security of having a same-sex interviewer. It has been demonstrated that this helps increase the comfort level of research participants while at the same time increasing the reliability/validity of self-reported behaviour concerning sensitive matters [Green & Browne, 2005]. Further, all four of our research assistants had university level educations, were fluent in both English and Luo, and were experienced in working with young people and making them feel safe. The vast majority of research participants expressed that they thought the interview process was good for them. In the course of answering the questions, they gained a better understanding of themselves and the dynamics of HIV infection and conflict.  This is a testament to the study team?s expertise and ability to collect credible data, a definite strength of this research. Finally, ethical aspects were thoughtfully considered and the local fieldwork team, supervisors and committee members were consulted when decisions had to be made about how to proceed in the field. Part of this process involved going beyond standard requirements outlined by the UNCST for conducting research in Uganda and included carrying out community preparation/sensitization, in the form of community meetings, prior to initiating recruitment and data collection. Although this pre-initiation activity may seem obvious, research team members and key informants on the ground relayed that community preparation was unfortunately not common. We conducted the meetings with interested community members and discussed the presence of researchers on the site(s) and raised awareness of the study. Community members were informed about the objectives of the study and its justification, and were reminded that the infection to be addressed is common. We ensured that community-level leaders (camp leaders) in particular were informed of the  210 initiative in efforts to maximize participation and reduce the risk of stigmatizing study participants. During recruitment, we achieved a near perfect response rate, with only one individual out of 385 young people that were approached, refusing participation. We believe this unusually high response rate attests to the effectiveness of the thorough community preparation process carried out prior to study commencement and highlights the importance and potential benefits of this often-neglected, yet crucial, research activity.  7.2.2 Unique contributions This study was among the first to provide population-level data on HIV prevalence and related vulnerabilities among young people in Gulu District, northern Uganda, and as such has contributed to filling a substantial gap in epidemiological evidence. Its findings provide an accurate understanding of the magnitude and determinants of HIV infection among young people ? females and males, abductees and non-abductees ? and presents data describing the legacy of the conflict on HIV/AIDS transmission, including identifying which groups are most vulnerable. This critical information has not been captured by antenatal studies or the Ugandan HIV/AIDS Sero-Behavioural Survey, currently the only sources of HIV epidemiological data available for the northern region [Westerhaus et al., 2008; Spittal et al., 2008]. Study findings contribute to the evidence base so desperately needed for the Government of Uganda and NGOs to identify areas in need of focus and to support, inform and prioritize effective responses to HIV among young people in post-conflict transition. Moreover, understanding the distribution of HIV within this population based on the analysis of the social, biological, and behavioural factors associated with infection offers new insights on HIV transmission in post-conflict settings, a subject area with a relative dearth of information.  211 An additional unique contribution of this research pertains to the analyses presented in Chapters 4 and 5, which demonstrated the practice of dry sex to be independently associated with HIV infection among young people, particularly young women. The relationship between the practice of dry sex and HIV infection has never been established in Uganda before and reinforces the need for context-specific responses to HIV. Fifty percent of sexually experienced young people in this study indicated having practiced dry sex and these same respondents also reported practicing dry sex at their last sexual encounter, demonstrating the common frequency of this sexual practice among Acholi people. Our findings are particularly important in informing appropriate prevention programming for young people in northern Uganda, as dry sex practices may directly contradict common HIV prevention messages, including the use of lubricated condoms and, more recently, microbicides. The elevated risk of HIV infection associated with the practice of dry sex that this study identified is substantial and warrants further research to test assumptions about which HIV prevention methods would or would not be acceptable in an area with a norm of dry sex, and conducting supplementary studies to gather information on user perspectives based on actual product use. 7.3 Limitations of Thesis Research A number of limitations specific to each analysis are described in Chapters 4 through 6. An additional discussion of these is presented here, as well as a description of other limitations. Concerns may be raised regarding the representativeness of the study sample and thus the generalizability of our study results. It was not possible to construct a complete sampling frame inclusive of all young people residing in transit sites in Gulu District due to the complex nature of the post-conflict returns process that was on-going throughout data  212 collection. Accordingly, a combination of proportional and non-proportional quota sampling was used, as random and systematic methods were not feasible in the transit camps because of the limited available data on the population and the unsystematic layouts of the camps. In addition, as stipulated by the study?s eligibility criteria, all participants were resident in a transit camp and we were therefore taking our sample from young people who may have faced greater challenges with resettlement than young people who were already re-settled in their home villages. While we cannot rule out selection bias and its impact on our parameter estimates, given that over 90% of the population of northern Uganda was encamped during the war, and Gulu District was the most heavily impacted District in the region, we believe that our sample including residents from 2 randomly selected sub-counties in the District is representative of conflict-affected young people living in Gulu District and that our study results can be generalized to this larger population. Another limitation lies within the design of the study. Our data are from a cross-sectional survey, which aimed to describe the relationship between HIV infection and behavioural, biological, and social factors as they exist in a specified population at one particular moment in time. Therefore, the identified associations between HIV positivity and risk factors do not inform us of their relative temporal sequence. We are unable to determine if HIV infection preceded or followed risk behaviours and are unable to identify cause-and-effect relationships. Prospective studies are required in order to make causal inferences in this regard and would offer a broader understanding of the determinants of HIV infection in this population. In the same regard, inferences drawn from study results must also be situated within the calendar time in which the data were collected. Data collection for this study occurred between September and December 2010; however, it would be expected that over  213 time, in a drawn-out post-conflict transition process, there would be some changes to the study population and introduction of new programmatic responses, including the scale-up of antiretroviral therapy to treat HIV-positive individuals. It is difficult to predict how these changes might affect study results, but longitudinal studies should be initiated to capture any effects these changes may have on HIV rates and determinants, and intervention efforts should be adjusted accordingly. Finally, because the data is based on self-report, we must acknowledge the potential limitation of social desirability bias. Previous studies on self-reported HIV risk behaviours found that individuals are likely to falsify or under-report experiences and behaviours that are too painful to recall or are illegal or stigmatizing, instead providing interviewers with what they believe to be socially desirable [De Irala et al., 1996; Latkin et al., 1993]. In these cases, non-response rates may also be high and hinder the representativeness of the sample to the target population [Fenton et al., 2001; Buve et al., 2001; Edgardh, 2000; Johnson et al., 2001; Ole-King?Ori et al., 1994]. To minimize the potential for social desirability bias and increase the reliability of responses, study questionnaires underwent a rigorous translation process and were pilot-tested to ensure that the terminology used in the questionnaire was culturally relevant, appropriate, and unlikely to cause offence and/or any misinterpretation and misunderstanding. Further, interviews were conducted in the local language and all participants were interviewed by a same-sex research assistant, to help increase the comfort level of research participants while at the same time increasing the reliability/validity of self-reported behaviour concerning sensitive matters [Green & Browne, 2005]. Acholi interviewers were extensively trained to establish rapport with study participants, and all interviews and testing took place in a private and quiet place of the participant?s choosing  214 and were conducted anonymously with no names or personal identifiers recorded. These approaches have been shown to minimize response bias and maximize reliability among respondents [De Irala et al., 1996; Green & Browne, 2005]. To assess the potential for social-desirability bias, and building on lessons learned from our previous studies in northern Uganda [Patel, 2008; Spittal et al., 2008], we supplemented questions regarding age of sexual debut and age at first marriage with questions pertaining to participants? friends? ages upon these same occasions in their lives. Interestingly, responses to both questions yielded a one-year-lower median age when participants were reporting on their friends? ages versus their own. These lower ages of sexual debut and first marriage were likely more accurate. Given that sex before the onset of menstruation was forbidden in Acholi culture as it was thought to yield stillbirth and infertility [Spittal et al., 2008], it is likely that the participants, when asked about themselves, were disclosing culturally desirable responses to avoid the shame associated with the disclosure of pre-menstruation sex.  7.4 Implications and Recommendations Potential implications, recommendations, and areas for future research relevant to each analysis included in this dissertation, are described in Chapters 4 through 6. Comprehensive insights and recommendations derived from the project as a whole are offered in the following section. 1. Post-conflict development support: Gradual withdrawal of aid Study findings, as well as the observed experiences of young people, demonstrate a clear need for continued support from governmental and aid organizations after the cessation of conflict. For example, 21% of young people in this study reported surface water as their main source of drinking water and nearly 10% indicated using the bush/field as their main toilet  215 facility. Forty percent of young people reported a current lack of food and/or water and 54% indicated not having had enough food to eat in the previous 12 months. Furthermore, 57% of participants reported that their access to basic needs and services (i.e., water, healthcare, education) in the transit camps was less than their access to these services while displaced in primary IDP camps and 70% of young people had been living in a transit camp for one to five years, which illustrates the drawn-out nature of the returns process. Shortly after the cessation of hostilities, the North was officially characterized as being in a period of ?recovery? and therefore all initiatives and funding were to be distinguished as development-related activities. As a result, many organizations focused on ?emergency? relief shuttered operations and withdrew support quite abruptly, as the context was now labeled as post-emergency. This resulted in significant gaps in programming including basic things such as the repair of boreholes, the construction of additional pit latrines and, infrastructure support for schools, as well as it resulted in large gaps in HIV programming. The risks faced by young people grew in what was now a difficult and prolonged transition period, as many families were not yet self-sufficient. There was a clear need for programming and assistance to continue in both IDP camps and transit camps for a longer period of time after conflict ended, in consideration of the time required to rebuild rural agrarian livelihoods. The protracted conflict and displacement in northern Uganda damaged traditional livelihood options and interrupted schooling, creating a generation of young people with limited access to income-generating activities or educational opportunities. Study findings suggest an obvious need for appropriate life-skills training and applicable education options for young people during the transition from conflict to recovery. Many NGO programmes have previously developed poverty-reducing interventions promoting skills training and  216 micro-enterprises (i.e., start-up and operating funds), but there have been no evaluations of the success of these programmes, leaving their actual impact on economic development and reintegration unknown [Blattman & Annan, 2008]. Even if effective, however, the promotion of entrepreneurial activities may be at best a short-term solution. Blattman & Annan [2008] suggest that increasing the supply of these services by the scaling-up of vocational training and enterprise development programmes will soon be constrained by a lack of demand. It is far from clear whether post-conflict economies can support more kiosks, more tailors, more charcoal production, or more boda-boda (motorcycle) taxis. The economics are simple: as these services increase, prices will fall, making such activities unprofitable for all [Blattman & Annan, 2008]. Hence, the only sustainable option for helping young people generate a real income appears to be a return to the original productive base of the northern Uganda economy - including a combination of subsistence farming, cash-cropping, and livestock rearing - yet there has been limited government or NGO focus on returning people to the land, increasing agricultural productivity, or re-stocking the cattle population of the north. Scaling-up of responses that encourage a viable return to subsistence-based lifestyles is critical as young people transition from conflict to recovery and may be the only practical option in achieving sustainable poverty reduction and long-term redevelopment. Furthermore, in post-conflict northern Uganda, age-appropriate educational options are urgently required for young people. Although 97% of young people in this study reported having being in school at some point, 74% had subsequently dropped out. Lack of money for fees and school materials (i.e., uniforms, books, pencils), being too old to rejoin after substantial time away, and pregnancy were the main reasons given for dropping out of school. The majority of the educational responses from government and NGOs in northern  217 Uganda have focused on keeping primary schools open and running. However, these programmes do little to help young people over the age of 15 years or young mothers with children. Best practices programmes, including secondary school scholarships/bursaries, accelerated adult education, and childcare and feeding for the children of students, are extremely rare and serve only a small fraction of the under-educated population [SWAY, 2007; Patel, 2006]. Given the widespread benefits of education for young people even in times of conflict and re-development [Patel, 2006; De Walque, 2004; Human Rights Watch, 2005b; Kasente, 2003; Santacruz & Arana, 2002; Annan et al., 2006; Wessells, 2006b; Sommers, 2003; Betancourt, 2005], support for formal and informal education programming should be dramatically scaled up. Alternative education should be accelerated and age-appropriate, offered in afternoons or evenings, with opportunities for childcare for young mothers.  There is a common but ill-founded belief that the end of conflict signals a time of social reconciliation, reinvestment in social development by national governments and an economic recovery that automatically benefits the general population [Carballo, 2009; Mock et al., 2004]. Donors seem to overlook the reality that developing countries typically go into conflicts with infrastructures that are already weak and then become even weaker as vital agricultural, educational and health systems are fundamentally disrupted or even completely destroyed. In this way, the needs and vulnerabilities of conflict-affected populations may even be greater post-conflict than during the conflict, necessitating continued assistance. Based on this, it is recommended that a gradual withdrawal of humanitarian relief post-emergency, one that is responsive to the rate of transition, coupled with resettlement  218 assistance focused on traditional livelihood re-development and the scaling-up of appropriate educational options, may be more appropriate. 2. Traditional prevention programming will not be enough Findings from this study demonstrate an unacceptably high HIV prevalence of 12.8% among young people in Gulu District. From this we can assume that in northern Uganda, current activities and approaches alone are insufficient or are ineffective in reducing high-risk behaviour in many instances. Further, the focus of programmes appears to be on the set of activities rather than on the persons affected or vulnerable to HIV/AIDS. Based on these assumptions and implications of our study findings, there is a need for HIV/AIDS programmes to reach beyond traditional prevention programming and be contextualized, so that the root causes ? the combination of factors ? that drive young people to behave in a manner that increases their vulnerability to HIV infection is appropriately addressed. The current approach to prevention of HIV transmission in developing countries has a standard set of activities, including training of community peer educators, introduction to STI management, opening of VCT centres, and provision of condoms and IEC materials [Westerhaus et al., 2008; Westerhaus et al., 2007; SMEC, 2005]. All of these activities may be necessary but possibly not sufficient to reduce HIV transmission in all environments. This standard menu of activities tends to be applied to differing contexts with little adjustment for location, and population-specific circumstances, or for the combination of factors driving the transmission of HIV [Westerhaus et al., 2008; Westerhaus et al., 2007]. For example, in northern Uganda many women engage in transactional sex to survive and/or depend on the precarious institution of marriage, where polygyny is the norm, divorce rates are high, and infidelity common. HIV prevention methods must encompass these actualities in places  219 where the traditional ABC method alone will achieve very little substantive impact; its simplified prevention strategies are likely to have only a peripheral effect considering the complicated structure of sexual relations in northern Uganda, particularly in the aftermath of war [Westerhaus et al., 2008; Westerhaus et al., 2007]. Abstinence and behavior change strategies fail to acknowledge how poverty and war strip individuals of personal choice essential to avoid HIV infection while, condom promotion programmes fail to protect women and girls who have limited negotiation power and are driven into transactional sex to meet basic living needs [Westerhaus et al., 2008; Westerhaus et al., 2007]. Given the post-conflict context of northern Uganda, the scope of traditional prevention programmes must be broadened to target the factors that drive and maintain high-risk sexual behaviour in this setting.  This study found that a non-consensual first sexual experience was a strong predictor of HIV infection in young people, particularly for young men. Twenty percent of young women and nearly 6% of young men reported that their sexual debut was non-consensual. Moreover, 29% of young women and 10% of young men indicated having been raped at some point in their lives and nearly 30% of young people reported experiencing physical/verbal/sexual abuse from sexual partners in the previous 12 months. Our findings emphasize the importance of addressing forced sex and other sexual and gender-based violence as an integral component of HIV prevention programmes. Traditional programming responses promoting abstinence, partner reduction, and condom use may overlook the reality of the lives of many young people in post-conflict transition, including the factors underlying their ability to choose whether or not to engage in sex and/or in making safe sexual choices. It appears that a more holistic approach is needed, including: broadening the understanding of  220 community members and local health service providers in regard to the relationship between sexual and gender-based violence and STI/HIV/AIDS; working with men and boys to change any harmful gender norms related to sexual responsibility, decision-making and violence; improving the communication and safer-sex negotiation skills of young people, particularly young women who commonly experience power imbalances in relationships, and; training providers to help improve attitudes about young people who have experienced sexual and gender-based violence, and provide clinical services that include emergency contraception, counseling, and reproductive health services. In addition, prevention programmes addressing sexual violence must recognize that males are also often victims and therefore must also be included in programming responses that are sensitive to their needs and their experiences of rape. Given the nature of the conflict in northern Uganda and the extent of violence experienced by so many people, it is critical that post-conflict HIV prevention initiatives address the underlying causes of violence, especially gendered violence. If they neglect to do so, they may become part of the HIV/AIDS problem, rather than assisting in an appropriate response.  Another study finding that has important implications for moving beyond traditional prevention programming is the demonstrated independent effect of the practice of dry sex on elevated risk of HIV infection. Our findings are particularly important in informing appropriate context-specific prevention programming for young people in northern Uganda because dry sex practices may directly contradict traditional HIV prevention messages, including the use of lubricated condoms and, more recently, microbicides. In this study, 91% of young men who indicated ever having practiced dry sex had never used a condom before. Further research must be conducted to test assumptions about which HIV prevention methods  221 would or would not be acceptable in an area with a norm of dry sex practices, and initiate supplementary studies to gather information on user perspectives based on actual product use. At present, raising awareness and knowledge levels of all community members (perhaps through IEC campaigns) on the elevated risk of HIV infection associated with the practice of dry sex must be a critical component of HIV prevention programming in northern Uganda. 3. Evidence-based policy: Targeting based on need Departing from the recognition of a paucity of HIV epidemiology in northern Uganda, this study sought to provide the evidence base needed for the Government of Uganda and NGOs to support, inform and prioritize effective responses to HIV among young people in post-conflict transition. An overarching finding from this research was that all young people ? males and females, abductees and non-abductees ? have been impacted by prolonged conflict and displacement and are in need of post-conflict supports. As such, post-conflict programme planners and policy makers must develop interventions based on evidence and well-identified needs rather than continue with rudimentary targeting based on high-profile categories of the population such as former abductees. While the impacts of abduction are real and cannot be ignored, a number of the reintegration gaps are small in comparison to the overall effects of war on all young people [Blattman & Annan, 2008; Annan et al., 2009]. For example, in this study, when comparing survival/livelihood activities and food insufficiency measures between former abductees and non-abductees, both overall and by gender, no significant differences were demonstrated. Our findings suggest that circumstantial targeting is likely to be unsuccessful in reducing young people?s vulnerability, in addressing their needs, and in improving the long-term reintegration of child soldiers. Rather, programming must be commensurate with young people?s needs. Responses that target based on specific  222 and identifiable needs ? education, livelihood development, sexual violence support ? are likely to be less stigmatizing as well as more inclusive and self-selecting, and yet they will still capture the most vulnerable by default. Moving from a system of circumstantial categorization to one based on specific, acute, and easily identified needs is critical and promises more effective and efficient targeting of assistance. Therefore, in post-conflict northern Uganda the aim should be to move from adhoc to evidence-based policy with programmes targeted to young people with the most serious educational, economic, psychosocial, and health challenges. 7.5 Conclusions The relationship between conflict and HIV/AIDS is complex in northern Uganda. Prolonged conflict, mass displacement and restrictions on movement did damage to social relations, eroded customary value systems, and destroyed traditional livelihood options. The risk that accumulates in such a situation gravely increases young people?s chances of acquiring HIV/AIDS and other STIs. Furthermore, the cessation of hostilities and end of formal displacement has led to a difficult and prolonged transition phase in which vulnerability persists. Collectively, the results from the quantitative epidemiological studies included in this dissertation establish the magnitude of HIV infection among young people living in post-emergency phase transit camps and characterize the context-specific factors that contribute to the spread of infection. Moreover, this study was designed to facilitate accurate comparisons of HIV-related vulnerability among sub-groups of young people within Gulu District ? males to females, formerly abducted to non-abducted - and provides strong evidence that all young people have been adversely affected by the war and are struggling and suffering. Clearly, the effects of war are persistent and generational. Study findings point  223 out the urgency of targeting interventions based on well-identified needs rather than circumstantial categorization, and reaching beyond traditional prevention programming by developing population-specific responses that are concurrently sensitive to local contexts and designed to address the complexity and underlying causes of factors influencing the spread of HIV among young people in post-conflict northern Uganda. Young people constitute a significant proportion of post-conflict societies. They come with a burden of traumatic experiences, but they also represent a vital and potentially crucial part of the recovery and reconstruction process. Confronting the realities of HIV can present a window of opportunity for strengthening the larger health development process and facilitating recovery. 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