Date of Award

Spring 5-14-2021

Degree Type


Degree Name

Doctor of Philosophy (PhD)


Public Health

First Advisor

Monica H. Swahn

Second Advisor

Richard Rothenberg

Third Advisor

Andrew L. Baughman

Fourth Advisor

Rachel Culbreth


Globally, HIV remains a critical public health issue with almost 40 million people currently living with HIV worldwide and millions who have died of AIDS since the start of the epidemic. As HIV affects the health of individuals, it also adversely impacts families, communities, and the development and stability of nations. Many of the countries hardest hit by HIV are resource-poor and suffer from other health issues and challenges. In Uganda, HIV prevalence among adults is still high and two-thirds of the urban population live in slum communities in the densely populated capital city of Kampala where lack of basic services negatively affects health and quality of life. The rapid growth of urban slums in the region is a cause for concern and data is limited on the health and risk behaviors of adolescents who live in these slums. Studies show that disease burden and premature death among adults can be associated with behaviors or conditions that began during adolescence. Youth who live on the streets and in the slums face much of the burden related to poverty, lack of family support, risk of HIV and other health issues. The three dissertation studies aimed to examine the drivers, contexts and patterns of high-risk and protective sexual behaviors which is critical for program development and interventions among understudied vulnerable youth and to complement the biomedical interventions that have greatly impacted the epidemic, but have not been able to achieve zero new infections. Using data from Kampala, the studies specifically aimed to: 1) examine the impact of individual level correlates of consistent condom use among sexually-active slum youth were examined to address and eliminate barriers to condom use in this sub-population of youth. Results showed that consistent condom use was low and was associated with condom use at sexual debut, no alcohol use before sex, condom use planning and self-efficacy; 2) examine the individual and community-level factors for engaging in multiple sexual partnerships among sexually active slum youth and whether sexual behaviors of the youth vary across the slum locations. We found a high prevalence of multiple sexual partnerships and that early sexual debut, alcohol use in the past year, alcohol use before sex and transactional sex were associated with multiple sexual partnerships. We also found that risk behaviors, including early sexual debut, alcohol use, and transactional sex varied greatly across the slum locations; 3) explore patterns of sexual risk behaviors and examine risk behavior and parental factors associated with these patterns. A latent class analysis was used to empirically identify three distinct classes of youth based on a set of their sexual risk behaviors, and examine the role of parental influence on the classes of sexual risk behavior. We found using alcohol before sex was a highly significant for youth in the high-risk class. Parental living status was also significantly associated with both the high risk and medium risk classes. The findings show that sexual risk classes have different behavioral and parental characteristics. The three studies highlight the need for tailored, targeted, multi-pronged programs, rather than a silo approach, to address multiple risk patterns, for effective HIV and STI prevention.


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