Synthesis Report

Publication Date
October 1, 2014

This 53-page report (and subsequent 6-page abridged report) discusses findings from a study to synthesise existing research to better understand HIV/AIDS prevention and care among sex workers in Uganda and inform the National HIV/AIDS multi-sectoral response. The study was conducted by the HIV/AIDS Knowledge Management and Communication Capacity (KMCC) initiative and included a literature review; interviews with researchers, academics, and practitioners; and discussions with sex workers. The study findings point to a need to upscale HIV prevention efforts designed specifically for people involved in various kinds of transactional sex.

The report first discusses how the concepts of sex work and transactional sex require a very complex understanding of the Ugandan context, and many involved in these kinds of relationships may not define their sexual behaviours as belonging to either category. This synthesis follows the UNAIDS description of a broad understanding of "sex work" as "the exchange of money or goods for sexual services, either regularly or occasionally... where the sex worker may or may not consciously define such activity as income generating". Using this guideline, the report notes that entry into sex work tends to happen at the same age range as the young person's non-commercial sexual debut (late teens) and that financial stress is the key driver for entry into sex work.

According to the report, "commercial sex work is one of the factors driving the HIV epidemic in Uganda and the rates of HIV infection and transmission observed in sex workers are far in excess of the levels found in the rest of the population." This is caused by factors such as multiple sexual partners, pressures to have sex without a condom, poor negotiating power, and, sometimes, violence. Another consideration is that the sex worker and client both usually have regular partners, i.e., spouses or girlfriend/boyfriends, who may also become infected.

The report provides information about different organisations and services currently working to address HIV/AIDS among sex workers, often involving sex workers as peer educators. Many include strategies to sensitise sex workers on safer sex and risks, as well as efforts to increase access to services. A number of programmes use a rights-based approach. Sex workers report that they are reluctant to seek out health services because of the poor treatment and discrimination they face at health facilities. However, aside from accessing health facilities, the study found that, although sex workers are acknowledged as an at-risk population, they have inadequate access to prevention programmes, voluntary counselling and testing (VCT), antiretroviral therapy (ART), and basic health services.

According to the report, various studies indicate almost universal knowledge among sex workers about HIV risk and prevention. Similarly, "when asked about knowledge regarding condom use as an HIV prevention strategy, nearly all female sex workers (97%) agreed with the statement, 'using condoms correctly and consistently reduces the risk of HIV infection.'" However, this knowledge is often not translating into consistent condom use. In a study of 12 areas frequented by sex workers and their clients in Uganda, 93.7% of sex workers and 86.8% of long-distance truck drivers reported they had used condoms in the last 30 days, but further assessment found only 44.9% of sex workers and 21.1% of truck drivers reporting consistent condom use during this same period. These findings were echoed by other studies.

While sex workers may have adequate knowledge and perception of risk, discussions pointed out that fears around this risk are overshadowed by more immediate and frightening threats such as violence from clients and pregnancy, which would prevent them from working and impact their financial independence. KMCC findings report a fatalistic attitude towards risk and HIV prevention, given their immediate need for money to buy food, care for a child, and pay for accommodation.

Overall, the study found that effective programming is often hindered by cultural, religious, and social dynamics that result in stigma, discrimination, and violence for sex workers. The report offers a number of recommendations, including the following, focused on implementing partners:

  • "involve sex workers and communities in designing, implementing and evaluating HIV/AIDS programmes and services;
  • tailor HIV/AIDS and STI counselling, prevention and care services to the needs in sex work settings;
  • provide comprehensive sexual and reproductive health packages;
  • promote the use of condoms and access to them;
  • run regular sensitisation and behaviour change campaigns targeting sex workers;
  • identify and develop champions for peer-to-peer education among sex workers; and
  • educate health workers to provide sex workers with non-coercive, confidential care devoid of discrimination or bias."

In conclusion, the report notes that "tackling HIV among sex workers will require changes in social and legal conditions that limit access to those HIV services. This will take time, but it is critical to implement the needed legal and policy reforms now and to pursue these actions with urgency and high-level support. The role of sex workers in the spread of HIV cannot be underestimated. There is an urgent need to target HIV prevention and research efforts to this vulnerable group."

KMCC has developed a six-page abridged report, as well as a number of other communications products to further disseminate the findings of the report.