Socio-ecological factors influencing access to and use of HIV testing, treatment and care services in fishing communities around Lake Victoria in Uganda

Socio-ecological factors such as poverty and mobility have been linked to HIV transmission in East African fishing communities. Little however is known about the influence of these factors on access to and use of HIV testing, treatment and care. To address this gap, in-depth interviews were conducted with 42 HIV positive fisherfolk and 15 health care providers from two HIV clinics located in two fishing communities in Uganda to identify socio-ecological factors influencing access to and use of HIV testing, treatment and care. Bronfenbrenner’s (1979) ecological systems theory guided the analysis of the above interviews. Informational, instrumental, affiliative and emotional support emerging from micro and mesosystem contexts facilitated access to and use of HIV testing, treatment and care. However, HIV-related discrimination present in these same contexts left some participants less supported in accessing services. Exosystem factors, including partner notification initiatives, facilitated some participants’ access to HIV testing, while occasional disruptions in supplies to clinics constrained the availability of HIV-related care. Macrosystem cultural factors, such as beliefs in traditional healing systems, delayed some fisherfolk’s access to HIV testing, while factors linked to the economic context in fishing communities including fisherfolk’s geographic mobility and poor transport systems regularly constrained access to treatment and care. Despite these difficulties, health service organisational factors were to a large extent successful in facilitating fisherfolk’s access to HIV testing, treatment and care. The effects of enabling and constraining factors and processes operating at each of these levels are identified in the thesis which also includes a diachronic analysis – using selected case studies – of the manner in which individual health and illness trajectories are impacted upon by different combinations of factors over time. Overall, the thesis contributes to a more nuanced, socially located understanding of factors influencing access to and use of HIV testing, treatment and care in fishing communities in Uganda. It highlights the need for programmes and interventions to engage more seriously with structural and contextual factors influencing fisherfolk access to services and support