Rakai Youth Project

Department Receives a $2.3 Million Grant from National Institute for Child Health and Human Development to Study Factors Associated with HIV Incidence among Youth in Rakai, Uganda

As reported in At the Frontline, the Mailman School's Heilbrunn Department of Population and Family Health received a $2.3 million grant from the National Institute for Child Health and Human Development (NICHD) to study the contextual and behavioral risk factors associated with HIV Incidence among Youth in Rakai, Uganda. In response on an internationally competitive Gender, Youth, and HIV RFA, the Mailman School is one of five institutions to receive this multi-year grant from the Demographic and Behavior Services branch of NICHD. The overarching aim of the NICHD initiative is to study the developmental and environmental processes contributing to HIV risk in individuals under the age of 24, specifically in settings where HIV prevalence is high and underlying contexts are changing rapidly.

Globally, an estimated 12 million young people aged 15-24 years are living with HIV/AIDS, which is for this age group the third leading cause of death worldwide and the leading cause of death in sub-Saharan Africa (SSA). Youth in SSA also experience high rates of other adverse reproductive health outcomes, including sexually transmitted infections (STIs), unplanned pregnancy, and maternal mortality. Myriad behavioral and social forces have been proposed as pathways to HIV infection and other adverse reproductive health outcomes.

Through political commitment and community mobilization, Uganda has made notable progress in containing HIV prevalence using a variety of prevention approaches including partner reduction, promotion of ABC (Abstinence, Be Faithful, Use Condoms), and openness regarding HIV. However, stable HIV incidence among young people (1-3% per year), increases in HIV risk behaviors, and new concerns about prevention fatigue and behavioral disinhibition have tempered optimism generated by Uganda’s prevention successes.

Dubbed the Rakai Youth Project (RYP), the initiative at the Mailman School will employ a unique biopsychosocial theoretical framework for sexual transmission of HIV infection that combines social contextual and social developmental perspectives with biological and behavior risk factors to explain risk for new HIV infections. The Rakai Youth Project (RYP) will first explore the changing patterns of HIV incidence among youth 15-24 years and will assess the influence of social and developmental risk factors for new HIV infections over time.

Using a unique existing longitudinal data set spanning 18 years and including a broad array of potential HIV determinants, researchers at the School will explore risk factors for HIV infection among youth. Specifically, the RYP will explore the social context, individual psychosocial and social developmental factors, sexual behaviors, and biological factors. RYP will compare the specifics of HIV risks by marital status and age of partners, by school attendance and achievement, and on the basis of pregnancy intentions and desires. Moreover, using qualitative data collection, RYP will explore the nuanced pathways between social and developmental factors and HIV infection—including the influence of HIV prevention programs, adolescent life goals and opportunities, peer pressure, relationship dynamics, and other social influences—that are difficult to fully capture in quantitative questionnaires.

A second project aim of the RYP will be to explore the specific role of HIV policies and programs in influencing HIV incidence among youth in the Rakai District. The RYP will explore changing HIV risk over four key “generations” of HIV prevention and care programs in Uganda: the “Zero grazing” era, the shift to ABC and abstinence education, the post anti-retroviral (ARV) treatment generation, and young people who have come of age after the advent of male circumcision (MC) availability.

The new availability of ARVs and MC has raised considerable concerns about behavioral disinhibition among youth. On the basis of the research findings, the RYP will develop recommendations for structural-level and educational interventions for youth in Rakai, Uganda, and elsewhere who are at-risk of HIV infection. Related research dissemination activities will be targeted strategically toward key policy and program leaders at the community, national, and international levels.

This innovative initiative will bring together investigators from Makerere University, the Uganda Virus Research Institute, and the Rakai Health Sciences Program in Uganda with Columbia University and Johns Hopkins University. The initiative will be led by Dr. John Santelli, professor and chair of the Heilbrunn Department of Population and Family Health. Dr. Serwadda, an infectious disease epidemiologist and professor and dean of the School of Public Health at Makerere University, Kampala, will serve as co-principal investigator on this initiative.

Additional investigators from the Mailman School of Public Health include Dr. Jennifer Higgins, assistant professor of Population and Family Health at the Mailman School, a specialist in in-depth qualitative and mixed-methods research exploring the intersections of gender, HIV risk, and pregnancy risk, and Dr. Ying Wei, assistant professor with the Department of Biostatistics at the Mailman School focusing on quantile regression, longitudinal data, and semi-parametric models.