Prevalence and Predisposing Factors of Human Immunodeficiency Virus Infection among the Boda-Boda Riders in Mbarara Municipality-Uganda

Background: Boda-Boda is a well-known and booming motorcycle taxi that employs youths to earn a living. They transport passengers at a faster rate where other means of transport are inaccessible or would be time consuming. Global statistics show that HIV has continued to be a major global Public Health issue especially among the “Most At-risk Populations” (MAPs) that include commercial transporters and Boda-Boda riders. Aim: This study aimed at assessing the prevalence and predisposing factors for HIV/AIDS among Boda-Boda riders living in Mbarara Municipality. Specifically, the study determined the prevalence of HIV among the Boda-Boda riders, identified social demographic predisposing factors for HIV and determined knowledge of Boda riders on prevention of HIV. Study setting: Boda-Boda operators in the transport sector are at high risk of HIV infection but the HIV status of the Boda Riders in Mbarara was not known a reason why the study was instituted: Study design: This was an analytical and descriptive cross-sectional study that employed quantitative methods of data collection. The study population comprised the registered Boda-Boda operators from two divisions of Kakoba and Kakiika in Mbarara municipality. Sample size and sampling methods: Using Morgan’s riders as preventive measure against HIV.


Introduction
Boda-Boda is a coined term in East Africa which originally referred exclusively to bicycle taxis and has in recent years, been expanded to refer to motorcycle taxis as well as tricycles [1]. It is one of the booming transport sectors in Uganda that employs a large number of youths to earn a living. In Uganda riding Boda Bodas has become a considerable source of income in almost all the districts for many youths, providing livelihood to themselves and their families [2]. In Uganda, Boda-Boda industry employs an estimated 250,000 youth (Kampala alone) and a source of livelihood to over 500,000 people in the country [3]. Daily monitor newspaper Uganda 2013, reported that Uganda spends 80 billion Ugandan shillings annually buying Indian bikes [4] and the country ranked third in motorcycle imports from India, behind Nigeria and Angola [4]. UN report (2018) shows that the Boda Bodas are so widespread in Uganda, and this sector is claimed to be the second largest employer of Ugandans [5]. Open Journal of Epidemiology Despite the significant contribution of the transport sector to Uganda's national development, there is unprecedented problem of HIV/AIDS seen elsewhere as an occupational hazard among truck drivers and motorcycle riders due to their lifestyle while on duty [6]. Studies done in Uganda and elsewhere have revealed transport as a social sector in the transmission of HIV in addition to other high risk behaviors like commercial sex work that fuel HIV epidemic.
Transport sector workers serve as bridge populations linking with the general population increasing their HIV infection acquisition risk twofold as workers in low-risk occupations and young people in the population [7].
Global statistics by UNAIDS 2019, show that HIV has continued to be a major global Public Health issue. By end of 2018, 44 million people globally were living with HIV; a cumulative total of up to 78.1 million had been infected since the start of epidemic and approximately 8.1 million did not know their HIV status [8].
Studies have shown that HIV/AIDS disproportionately affects population and the risk has been found very high among special groups of people categorised as most at Risk [9]. These include drug users, transgender, sex workers, and men who have sex with men. Other than what is mentioned here, ranking high in behaviour risk are long distance truck drivers and the Boda-Boda riders who are mainly youths that are sexually active, adventurous and vulnerable to acquire HIV/AIDS. The transport sector in general is a means of spread and transmission of HIV/AIDS because of the constant stream of large numbers of people along transport routes. The term Boda-Boda originated from eastern Uganda, in towns bordering Kenya and Uganda like Busia, Malaba and Lwakaka: It referred to boys/men on bicycles who offered to smuggle goods and individuals across the border. The term "Boda-Boda" itself is the way Ugandans and Kenyans pronounce the phrase "border-border" when offering their services [10]. While Boda-Boda initially existed solely in the form of bicycle transportation, the term soon grew to encompass those who offered motorcycle transportation as well. The risk of HIV infection among the Boda-Boda elsewhere is influenced among others by, low knowledge levels on HIV transmission and prevention, limited access to HIV counseling and Testing (HCT) to establish one's sero-status and low condom use. HCT has proved very successful as a form of HIV prevention in Eastern and Southern Africa [11]. A study in South Africa found that HIV testing and Counseling among 4000 young people meant 41% fewer cases of HIV transmission in a four year period [12].
Studies have demonstrated that Condom use is an important strategy that helps prevent HIV transmission by reducing the risk of an exposure to HIV during sex [13]. This is because a condom provides a physical barrier to the vi-  [14]. Studies elsewhere have also shown that the risk of low condom use among the young people is further compounded by having multiple sexual partners. This is seen in countries mostly affected by HIV pandemic [15]. A case in point is that of Lesotho, Madagascar and Eswatini where more than a quarter of young men have been found to have multiple relationships [16].
Boda-Boda riders having been identified as being highly vulnerable to HIV transmission through the transport sector because of their engagement in risky behavior, the need for critical investigation of this problem is ostensible. There is no study that has been carried out to ascertain the prevalence of HIV infection among the Boda-Boda in Mbarara Municipality, therefore information on prevalence and social demographic risks in this population is virtually non-existent.
Results of this study should be of value to Mbarara municipality health services for planning specific intervention for Boda-Boda as a high-risk group.  Table 1 further reveals that, 20 (15.4%) riders of the married riders had two other sexual partners, 6 (4.6%) had 3 and 11 (8.5%) with more than 3. Almost a half of the Boda-Boda riders 174 (46.4%) had been riders for more than 3 years.

2) Prevalence of HIV among Boda-Boda riders
Using determine strips first, those tested reactive were confirmed using Unigold. Overall HIV prevalence among the Boda-Boda riders was 9.9% (Table 2 below). About 292 riders were tested from Kakoba division and 81 from Kakika division. The prevalence of HIV was highest (13.6%) in Kakika division and slightly lower 8.9% in Kakoba division. Prevalence among the single riders and those with one wife was 9.3%, those with more than three girlfriends/lovers 18.2%), those of Rwandese origin 18.2%. Among those that completed primary level of education (12%), those who had never heard of HIV/AIDS screening 25%, among the riders who said that HIV cannot be cured (10%) while those having more than one partner (multiple partners) it was 38%.

3) Boda-Boda riders' knowledge on HIV and HCT screening
From  How are HIV patients managed?
• By praying 3 (0.87) • By taking all the medicines given correctly throughout lifetime 316 (92.1) • By taking all the medicines as prescribed until one feels better 18 (5.3) • I don't know 6 (1.8) Do you feel people with HIV should get treatment and continue riding bodaboda?
• Pastors who will pray for them 4 (1.1) • Traditional healers who will consult to forgive them 2 (0.55) • Results in Table 7 below revealed that the riders who had never heard of Open Journal of Epidemiology

Discussion
This study aimed at establishing the prevalence of HIV among the Boda-Boda riders, social demographic factors predisposing them to HIV and their knowledge on HIV infection. Findings indicate that 91.8% of the Boda-Boda riders were married to one wife; this was a very good practice in HIV prevention. Studies elsewhere have demonstrated that multiple concurrent sex partners clearly have the potential to accelerate the spread of HIV beyond serial monogamous relationship [17]. In this study, findings further revealed that, Boda-Boda riders who had multiple partners 61.54% were six times more likely to acquire HIV/AIDS compared to those who buy sex from prostitutes Table 2. From Table 1 [19] found that the prevalence of HIV among the Boda-Boda riders was 7.5%, higher than 4.5% in other men and national prevalence of age bracket in Uganda. This agrees with World Bank report [20] claim that transport is a high-risk occupation. Other studies already alluded to the fact that the transport sector is a major vector in the transmission of HIV/AIDS [21]. This is because the high mobility of workers In this study general knowledge of the riders on HIV infection and importance of VCT services was at 80%. This was a good finding and could be attributed to the fact that, Most of the riders had taken more than three years in the Boda-Boda industry together with the fact that the riders had high literacy levels.  [22] where riders in transport sector with 1 to 4 years' experience of riding commercial motorcycles had exposed them to health information on HIV prevention. To the researchers dismay however, rider's practices on condom use as a preventive measure were found low at 44.3% among the respondents. The Boda-Boda rider's good knowledge on HIV prevention by correct use of condoms did not therefore match with the practice. Low condom use in this study could be linked to the problem of multiple sexual partners where other studies have shown inconsistence use of condoms on stable multiple sexual partners.
In this study, 95% of the respondents were aware of HIV/VCT screening services at least from health workers ( Table 6 and Table 7). The finding shows that the Boda-Boda riders are informed about how one can determine their HIV Sero status and even take precautions against HIV. Riders who had never heard of VCT/HCT screening for HIV were three times likely to acquire HIV compared to those who ever heard of VCT/HCT screening (OR = 3.35; 95% CI 1.14 9.83; p = 0.027). This could be attributed to lack of knowledge on transmission and prevention of HIV and might be attached to failure to articulate health education message more especially among those with no formal education.

Conclusion
The prevalence of HIV among the Boda-Boda riders in Mbarara municipality at 9.9% is higher than 5.7% national HIV prevalence [23] and 6.1% [18]

Limitations
Due to stigma associated with HIV, some respondents were reluctant to discuss HIV/AIDS. Very sensitive questions like a person living with AIDS or the death of a person of HIV/AIDS were asked last. Some riders were not fluent in spoken English; the study was therefore carried out in both English and Runyankore to special cases by research assistants. Some respondents declined to receive their results but they were tracked through their leaders at all level and further counseling was performed before the release of results. Finally, our data did not include sexual partner type, in particular homosexual partnerships which have been associated with HIV risk among young people. These are areas for further research.