Uganda is short on data on HIV among the country's sex workers, but a new study shows that in the capital, Kampala, HIV prevalence among female sex workers could be more than four times the city's average prevalence.
The study, published in April in the Journal of the American Sexually Transmitted Diseases (STI) Association, recruited 1,027 women from the city's red-light areas, and found 37 percent to be HIV-positive, while 13 percent had gonorrhoea and 10 percent had syphilis.
According to the government, Uganda has an average national prevalence of 6.4 percent; in Kampala, that figure rises to 8.5 percent.
The study recommended HIV prevention interventions, including regular STI screening; voluntary HIV testing and counselling; condom promotion and counselling for reducing alcohol use.
However, according to local NGOs, the illegal nature of the trade makes sex workers difficult to reach with HIV-prevention services. "They plead with us, saying, 'please doctor, is there some way we can get services and not go to the clinic? When we go to the clinics we meet our clients and that spoils our business'," said Henry Kibira, who works with the NGO, InterAid Uganda, in the central Ugandan district of Rakai.
"The problem is that there is no clear framework to deal with the commercial sex workers," said Catherine Nandago of the Uganda chapter of the Alliance of Mayors and Municipal Leaders' Initiative for Community Action on AIDS at the Local Level (AMICALL). "When you approach them they think you are bringing police, who harass them all the time."
She said police harassment - and often rape by law-enforcement officers - was an issue that needed to be urgently addressed.
According to Geoffrey Bwambale, a health worker from South Rwenzori in western Uganda, many sex workers continue to practise even after being diagnosed with HIV. "After testing they know that they are HIV-positive and relocate to other towns. We bump into them when we travel but cannot say anything."
One strategy that does seem to be having some success is the use of sex workers as peer educators.
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"We involve leaders of commercial sex workers in consultative and planning meetings. This has helped to identify working strategies that ensure ownership and success of planned interventions," said AMICALL's Nandago. "Peer education has proven to be a very effective tool for sensitization and for mobilization of commercial sex workers for HIV/AIDS services like home counselling and testing, anti-retrovirals and other related services.
"Many are able to negotiate for condoms; they used to say, 'men give us small money - 5,000 shillings [US$2] - for protected sex, and 10 times that amount for unprotected sex'," she added. "But now they say, 'even if he gives me all that money, I want to protect myself’."
The challenge, Nandago added, was that the peer educators often decided to change locations in search of more money, so the training was a constant process.
The government reports that sex workers, their clients and partners of clients contribute 10 percent of new infections in Uganda. According a 2009 HIV Prevention Response and Modes of Transmission Analysis report by UNAIDS and the Uganda AIDS Commission, special programmes for commercial sex workers and their clients are not of a large scale, nor comprehensive.