HIV and AIDS have had a devastating impact on mankind with varying effects at individual, family, community and institutional levels. Globally, 33 million people were estimated to be living with HIV in 2007[1]. Over the years, HIV concentration remains dominant in Sub-Sahara African countries which accounted for 67% of all people living with HIV in 2007[1]. Uganda has not been spared either, with an estimated HIV prevalence of 6.4% [2]. Results of the Uganda sero-behaviour survey conducted in 2004-05 revealed higher HIV prevalence (8.2%) in the North Central region which includes Gulu, Kitgum, Pader, Lira and Apac districts. This prevalence is comparable to the highest rate of 8.5% in Kampala the capital city and the central region [2]. The high HIV prevalence in the North-Central region could partly be explained by an over 20 year old war between the Government of Uganda and the rebels of the Lord's Resistance Army (LRA)[3]. War and conflict remain major threats to health[4].The Uganda Country progress report on HIV and AIDS 2008[5] highlights co-existence of high HIV prevalence in the conflict areas of Northern Uganda and limited programme coverage as a major challenge. Ill health in conflict areas including the spread of HIV could be exacerbated by negative social cultural practices that increase vulnerability to HIV infection. With relative peace following cessation of hostilities agreement by the Ugandan Government and the rebel group the LRA, several internally displaced persons started returning to their villages[3, 5]. This presented need by development agencies including Concern Worldwide in Uganda to develop livelihood programs to address the changing needs of the poor returnees. To ensure that HIV and AIDS issues are well understood and addressed in return villages, we conducted operational research to explore community perceptions on HIV and AIDS as a community problem and its linkages to culture and insecurity in Pader District, Northern Uganda.

Community members in Pader District highly recognised HIV and AIDS as a community problem. However, the threat of HIV and AIDS was overshadowed by other pressing community needs especially those related to immediate survival such as water, sanitation facilities, food, medical care and shelter. These services were particularly lacking in return villages compared to camps. These findings reflect multiple vulnerabilities which should be central in the design of livelihood enhancement interventions for returnees in Pader district of which HIV and AIDS mainstreaming should be part. It should be noted that lack of social economic rights have been found to augment the risk of HIV infection [14]. The implication here is that HIV and AIDS should be part of all community development, reconstruction and rehabilitation interventions in Pader district which has been largely affected by conflict. Government and civil society actors should go beyond the traditional HIV interventions and address the complex realities obtaining on ground including increasing access to food, income generation and health care services among returnee populations. Opportunities for HIV and AIDS mainstreaming within livelihood projects should be identified and utilised to foster HIV prevention, care and support. For example, community leaders suggested that HIV messages like use of condoms and the need for people to go for HIV counselling and testing could be provided to communities while commissioning community water projects or during the distribution of agricultural inputs. Such insights from communities provide a window of hope to contain the HIV epidemic in the post conflict phase but also challenge development actors to address the multiple vulnerabilities to HIV infection of individuals, households and communities resulting from conflict. Addressing such the community livelihood needs has potential to restore hope for the future among returnees a likely premise for effective behaviour change messages for HIV prevention[15].

The linkage of HIV and insecurity was appreciated by most community members and district officials. To this end, insecurity was understood to have led to increased sexual immorality, displacement of populations, prostitution, rape and defilement, poverty and strain on existing health services which were associated with increased risk of HIV transmission. This community perception is not surprising given the high HIV prevalence in northern Uganda (8.2%) comparable to that of Kampala (8.5%) [2] the capital city of Uganda. These rates remain far higher than those observed in other rural areas of Uganda. This concurs with Fabiani et al and colleagues who noted that, antenatal HIV prevalence in Acholi region of Northern Uganda is higher than the rates reported in other rural areas of Uganda [16]. This is attributed to the social and economic crises resulting from the civil strife that has affected the region since 1986 [14, 16]. Conflict has resulted into breakdown of community social structures with negative impact on health indices in the region. For instance the WHO health and mortality survey conducted in Northern Uganda in 2005 [3] revealed that the crude mortality ratio and under five mortality in IDP camps were above emergency thresholds i.e. 1 and 2 per 10,000 per day. The leading causes of mortality were malaria and HIV and AIDS related complications[3]. Our findings re-affirm insecurity as a major threat to health [4]. The recent Uganda Country progress report on HIV and AIDS 2008 [5] highlights co-existence of high HIV prevalence in the conflict areas of Northern Uganda and limited (HIV and AIDS) programme coverage as a major challenge. The vulnerability and need for prioritisation of displaced populations has been highlighted as a precondition in attaining universal access and the Millennium Development Goals[17]. Ciantia in a review paper concluded that conflict creates conducive environment for factors that increase the risk of HIV infection though this may not necessarily translate into higher prevalence [18].Similar arguments have been raised by Becker and colleagues who underscore conflict and society disarray that follow as a unique and conducive environment to increase the spread the HIV epidemic [19]. Indeed IDPs are often isolated and relatively inaccessible characterised by poor government infrastructure and systems[17]. These are directly linked to civil strife[16]. For sustainable impact of development interventions during the post conflict and reconstruction phase, programme designers and implementers should address issues of HIV at community level as part of the development programmes. In addition, the capacity of health care facilities to deliver HIV and AIDS services in the post conflict Pader district should be stepped up.

Study findings revealed that men, women and youth in IDP camps adopted risky practices that increase vulnerability to HIV infection including sex for money and material gain as well as alcoholism because they were desperate owing to the displacement caused by insecurity. Thus broader and long-term community development interventions that target the survival and development needs of formally displaced populations including health, water, sanitation education, food security, income generation and skills building among others are urgently required to restore hope, confidence and self esteem among returnee populations to foster appropriate behaviours and practices for HIV prevention, care and support. Consistent to the proposal of rebuilding individual and community assets and capabilities for HIV prevention in the post conflict Pader district, Barnett and Weston observed that the hope environment can influence HIV and AIDS prevalence. They observe that people with hope for the future and plans for achieving future goals are less likely to engage in activities in the present that put them at risk of illness or death in the future[15].

Contrary to our findings, emerging evidence seem to suggest lower risk of HIV infection among Internally displaced persons (IDPs) when compared to non IDPs [16, 19, 20]. A likely explanation to this scenario has been offered by Fabiani et al [16] and Westerhaus [14] who argue that, isolation of populations due to insecurity offer a protective effect holding HIV prevalence down despite the high prevalence of rape, transactional sex and lack of preventive interventions [14].Forced displacement has also been associated with reduced social networks in which individuals might be exposed to HIV[20]. Another study carried out in Northern Uganda highlighted issues of overcrowding in camps, over drinking and poverty which affected both physical and mental health of displaced populations in Nothern Uganda[21]. These social determinants work to increase the risk of contracting HIV amongst IDPs. Although it is possible that IDP camps in Pader district, might have had limited population mobility as a protective factor in the spread of HIV; this is gradually fading away as people return to their villages following relative peace in the district. What emerges from this study is that, the risk of HIV infection is likely to increase as people leave camps to their areas of origin if not followed with appropriate HIV prevention and care interventions. In addition, population mobility within and outside the district is also likely to increase, again presenting need to strengthen and expand HIV prevention and care services. The main worry is that reconstruction periods after conflict might even be associated with increased risk of HIV transmission than during conflict [19, 20].

Cultural practices like polygamy, widow inheritance, early marriages, alcoholism and silence about sex were linked to the spread of HIV in both IDP camps and return villages. These findings are in agreement with other studies conducted in the Acholi region. For instance, Westerhaus noted that men usually pursue polygamous relationships [14]. The Uganda sero-behaviour survey (2004-05) revealed prevalence of polygamy among married women (33.3%) and men (28.7%) aged 15-49 in northern Uganda which includes Pader district [2]. Polygamy a form of long-term concurrent sexual partnership is one of the key explanations for the high HIV prevalence in Africa [22]. The challenge of concurrent sexual partnerships should be centralised in the development and implementation of HIV and AIDS behaviour change and communication interventions in Pader District. The risk to HIV transmission in northern Uganda is compounded by excessive use of alcohol, a risk factor for unsafe sex [2]. Indeed another study conducted amongst internally displaced persons in Northern Uganda highlighted over drinking as an effect of the war and a cause of ill health[21].

The gender dimensions of vulnerability to HIV infection emerged in this study. Most study participants believed that women and girls were more at risk of HIV infection than men owing to rape, defilement and power imbalances between men and women with regard to sexuality. The gender dimensions of HIV transmission have also been documented by other studies [14, 23, 24]. The situation is even worsened by the struggles for survival and family sustenance shouldered by women in conflict areas like fetching water and collecting firewood which are likely snares for rape [25]. Livelihood reconstruction programmes should thus address the gender and livelihood based vulnerabilities to HIV infection. For instance, interventions should include components in areas of protection for women and girls from sexual violence, vocational skills training and income generating projects.

Perspectives of community members and district leaders, revealed the perceived inter-linkages among HIV, war and culture which are critical for an effective HIV intervention. Mainstreaming HIV and AIDS into development interventions aimed at addressing the pressing needs of returnees should be a concern for all stakeholders involved in the design and implementation development interventions. However, the qualitative nature of our findings presents a challenge for trends analysis. The findings of this study are in agreement with those of other studies that highlight insecurity and the social cultural factors that increase the vulnerability of populations to HIV infection[14, 16, 17] and ill health[21]. Community problems might have been exaggerated by some study participants to attract sympathy for support from NGOs. However, triangulation owing to use of multiple sources of data and different data collection methods helped to check the consistency and variations in study findings [26]. Indeed, findings from FGDs with different sub-groups and key informants at community and district levels were generally in agreement on the perceived linkages among HIV, insecurity and culture. The effect of social expectations from NGOs on study findings could be regarded as minimal. Whereas caution should be taken in attempts to use these findings beyond the study communities, the insights generated with regard to HIV and AIDS mainstreaming in post conflict interventions, the need for broader development interventions matched to the varied pressing needs of returnee populations as an entry point for HIV and AIDS and a source of hope for HIV prevention, care and support may be transferable and applicable to the wider Northern Uganda region that has suffered from the same war and its effects. We were not able to interview representatives of special groups including commercial sex workers and victims of rape and gender based violence. Future studies should seek to involve these groups for more understanding of contextual issues that drive vulnerability and risk to HIV infection in post conflict settings.

Our study has demonstrated that HIV in return villages is currently overshadowed by other pressing community needs like water, food, health care, sanitation and lack of income generation opportunities. The voices of communities and leaders in this study stress the need for HIV mainstreaming in all community development and reconstruction interventions in Pader district and Northern Uganda in general to increase programme relevancy, acceptability and potential for success. Development actors including civil society organisations, central government, district administration, religious and cultural leaders as well as other stakeholders should prioritise HIV mainstreaming in the design, implementation and evaluation of community development interventions in the post conflict reconstruction programmes in Pader district. Addressing the vulnerabilities to HIV infection for women, the youth and men resulting from conflict and displacement should be a central building block in programme design, implementation, monitoring and evaluation. Advocacy and negotiation to end the long standing conflict in northern Uganda should remain a priority in the broader development framework; otherwise interventions will at best continue to fall short of addressing the causes of vulnerability to HIV infection and suffering in the region. Negative cultural practices that increase the risk of HIV infection like; polygamy, widow inheritance, early marriages, alcoholism and silence about sex should be addressed through comprehensive behaviour change and communication interventions. Studies are required to closely monitor changes in incidence and prevalence of HIV in Pader district and northern Uganda in general especially in the post conflict period as more of the formally displaced persons return to their villages. Further operational research to document the effect of HIV mainstreaming in development and livelihood interventions on HIV prevention, care and support is required to improve the effectiveness of development interventions and generate evidence for replication of successful programmes and advocacy for development actors to better meet the needs of conflict affected populations.