Background: We determined the prevalence of and risk factors for alcohol misuse and illicit drug use among young Ugandans in fishing communities, a recognised “key population” for human immunodeficiency virus (HIV) infection. Methods: We conducted a cross-sectional survey among young people (15–24 years) in fishing communities in Koome, Uganda, in December 2017–July 2018. Using Audio-Assisted Self-Interviewing, we collected data on socio-demographic characteristics and alcohol use, including the Alcohol Use Disorders Identification Test (AUDIT) and timeline follow-back calendar (TLFB). Blood samples were analysed for HIV, herpes simplex virus 2 (HSV2), and Phosphatidyl ethanol (PEth 16:0/18:1). Urine samples were analysed for illicit drugs. Results: Among 1281 participants (52.7% male, mean age 20 years), 659 (51.4%) reported ever drinking alcohol, 248 (19.4%) had 12-month-AUDIT ≥ 8, and 261 (20.5%) had whole-blood PEth 16:0/18:1 concentration ≥ 20 ng/mL, indicating significant consumption. In multivariable analyses, PEth 16:0/18:1 ≥ 20ng/mL, AUDIT ≥ 8 and binge drinking (≥6 standard drinks per drinking occasion in the previous month from TLFB) were all strongly associated with older age, low education, smoking, and HSV2. Illicit drug use prevalence was 5.2% and was associated with older age, low education, being single, and smoking. Conclusion: Levels of alcohol misuse were high among young people in fishing communities and associated with HSV2, a proxy for risky sexual behaviour. Alcohol and illicit drug harm reduction services and HIV prevention programs in Uganda should prioritise young fisherfolk.

We used a discrete choice experiment to assess the acceptability and potential uptake of HIV pre-exposure prophylaxis (PrEP) among 713 HIV-negative members of fishing communities in Uganda. Participants were asked to choose between oral pill, injection, implant, condoms, vaginal ring (women), and men circumcision. Product attributes were HIV prevention effectiveness, sexually transmitted infection (STI) prevention, contraception, waiting time, and secrecy of use. Data were analysed using mixed multinomial logit and latent class models. HIV prevention effectiveness was viewed as the most important attribute. Both genders preferred oral PrEP. Women least preferred the vaginal ring and men the implant. Condom use was predicted to decrease by one third among men, and not to change amongst women. Oral PrEP and other new prevention technologies are acceptable among fishing communities and may have substantial demand. Future work should explore utility of multiple product technologies that combine contraception with HIV and other STI prevention.

Validated tools for assessing alcohol use among young people in low-income countries are needed to estimate prevalence and evaluate alcohol-reduction interventions. We validated Alcohol Use Disorders Identification Test (AUDIT) against Timeline Follow Back (TLFB), Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and phosphatidylethanol (PEth); and the 30-day-AUDIT against the 12-months-AUDIT among young Ugandans. In 2018, we collected retrospective data on 30-day and 12-month AUDIT, TLFB and DSM-5 in a cross-sectional study of 15-24 year old residents of Ugandan fishing communities. AUDIT was administered by Audio Computer Assisted Self-Interviewing (ACASI) and DSM-5 and TLFB by psychiatric nurses. We determined PEth16:0/18:1 levels from dried blood spots using liquid chromatography tandem-mass spectrometry (heavy usage, ≥210 ng/mL) and calculated sensitivity and specificity of AUDIT against the other measures. Among 1281 participants (52.7% male, mean age 20 years), half (n = 659; 51.4%) reported ever drinking alcohol, 19.4% had 12-month-AUDIT ≥ 8 (21.5% men; 17.0% women), and 24.2% had 30-day-AUDIT ≥ 8 (29.0% men; 18.9% women). Twenty percent of participants had detectable PEth with 55 (4.3%) classified as heavy drinkers; 50.7% reported ≥ 2 symptoms on DSM-5 and 6.3% reported binge drinking in the previous month based on TLFB (8.9% men, 3.5% women). The 30-day-AUDIT ≥ 8 had sensitivity 86.7%, 95%CI: 81.8%-90.7% and specificity 90.9%, 95%CI:89.0%-92.6% versus 12-month-AUDIT ≥ 8. Both 30-day and 12-month-AUDIT ≥ 8 were sensitive and specific markers of heavy drinking by PEth (12-month-AUDIT sensitivity = 80.0%; 95%CI:67.0%-89.6%; specificity = 83.3%; 95%CI:81.1%-85.3%). The 30-day-AUDIT was a sensitive and specific marker of binge drinking based on TLFB (sensitivity = 82.7%; 95%CI:72.7%-90.2%, specificity = 79.8%; 95%CI:77.4%-82.1%); 12-month-AUDIT had lower sensitivity. Both 30-day and 12-month AUDIT ≥ 8 were highly specific but insensitive markers of having DSM-5 ≥ 2 symptoms. Among young people in Uganda, ACASI-administered 30-day and 12-month-AUDIT have good diagnostic properties compared to PEth, DSM-5 and TLFB. Self-reported AUDIT provides a quick and valid means of assessing alcohol misuse in these communities.

Occupational groups at high-risk of HIV in sub-Saharan Africa (SSA) may be at increased risk of substance use because of occupation-related factors. We synthesised qualitative data on determinants and context of alcohol misuse and illicit drug use in these groups. We systematically searched five databases for qualitative studies reporting on alcohol misuse or illicit drug use in fisherfolk, uniformed personnel, miners, truckers, motorcycle taxi riders, and sex workers in SSA. Qualitative data and interpretations were extracted and synthesised using a systematic iterative process to capture themes and overarching concepts. We searched for papers published prior to January 2018. We identified 5692 papers, and included 21 papers in our review, published from 1993 to 2017. Most studies were conducted among fisherfolk (n = 4) or sex workers (n = 12). Ten papers reported on alcohol use alone, three on illicit drug use alone and eight on both. Substance use was commonly examined in the context of work and risky behaviour, key drivers identified included transactional sex, availability of disposable income, poverty, gender inequalities and work/living environments. Substance use was linked to risky behaviour and reduced perceived susceptibility to HIV. Our review underscores the importance of multilevel, integrated HIV prevention and harm reduction interventions in these settings.

We assessed feasibility of an HIV-combination-prevention trial among fishing communities in Uganda. Cluster randomised trial in four fishing communities on Lake Victoria, Uganda. Two intervention communities received a combination-prevention-package (behaviour change communication, condom promotion, HIV testing, voluntary male medical circumcision and referral for anti-retroviral therapy if HIV-positive). All four communities received routine government HIV care services. Using household census data we randomly selected a cohort of consenting residents aged ≥18 years. A baseline sero-survey in July 2014 was followed by two repeat surveys in March and December 2015. We measured uptake of HIV prevention methods, loss-to-follow-up and HIV incidence, accounting for multistage survey design. A total of 862 participants were enrolled and followed for 15 months. Participation was 62% and 74% in the control and intervention arms respectively; Overall loss to follow up (LTFU) was 21.6% and was similar by arm. Self-reported abstinence/faithfulness increased between baseline and endline in both arms from 53% to 73% in the control arm, and 55% to 67% in the intervention arm. Reported condom use throughout the study period was 36% in the intervention arm vs 28% in the control arm; number of male participants reporting circumsicion in both arms from 58% to 79% in the intervention arm, and 39% to 46% in the control arm. Independent baseline predictors of loss-to-follow-up were: being HIV positive, residence in the community for 1 month/year Recruitment and retention of participants in longitudinal trials in highly mobile HIV fishing communities is challenging. Future research should investigate modes for locating and retaining participants, and delivery of HIV-combination prevention.