The study of knowledge and sexual behavior patterns related to HIV/AIDS among commercial sex workers in Kampala was carried out in Katanga slum area. This area is situated in a valley that separates Makerere University and Mulago Hospital, 3 Kilometers northwest of Kampala city center, the capital city of Uganda. The data presented and discussed in this study was collected exclusively from sex workers who were willing to be interviewed by the researcher. The data was collected between June - July 1996. Data analysis and report writing was done in the subsequent months.
A total of 201 sex workers were enrolled in the study from all the four administrative zones of Katanga slum area, namely,: Kimwanyi, Soweto, Katale and Busia zones. 66.5% of the sex workers were in the age group 15-24 years, the age group from which 60% of all the new HIV infections have been reported in Uganda. Also, in this age group, HIV infection rates are six times more in females than their male counterparts nation wide. This age bracket, therefore, constituted a major demographic risk group to HIV/AIDS among women where intervention needs to focused. The majority of sex workers had very low educational status, the highest level attained by 83.9% being skewed to primary and nursery levels or none. This implied that most of them had difficulty in getting gainful employment, and at best could only be engaged in low paying service jobs such as serving as barmaids, food vending and petty trade, which could not meet their daily needs. Not surprisingly, almost half of them were jobless (41.9%), while the rest were involved in various kinds of menial work already mentioned. Lack of financial support was one of the risk factors which made them vulnerable to sex work. Thus, for any successful intervention among sex workers, the problem of unemployment needs to be addressed, through the initiation of income generating activities to provide alternative sources of income to sex work. Most sex workers are Protestants and Catholics, and a few are Moslems, which more or less reflected the national picture.
The majority of sex workers belong to the Baganda ethnic group. This is probably due to their proximity to the capital city, where a lot of rural to urban migration takes place in search of urban-western life styles and employment opportunities. It has also been observed for decades in Uganda that many young women from the western parts of Uganda, particularly those belonging to Batoro and Banyankole, have been migrating to major cities where they reside in slum areas engaging in sex work as a means of survival. Many of these young women are brought to the cities by their relatives in search of low-income jobs and later introduced to the sex trade. However, apart from the historical responsibility of migrant labor for the growth of prostitution that has been documented, recent civil wars and strife in various rural parts of the country have also driven many young women into cities with no financial support.
Most sex workers (77.1%) had no spouses, as the majority were single young women, while others were divorced or widowed. Despite this observation, the majority (79.5%) had a number of children ranging between 1 to 5 siblings showing a high fertility index and low use of family planning methods in such a young population. It also implied that most sex workers, in addition to commercial partners, also had steady partners whom they regarded as their "husbands" and whom they preferred to have children from; hence they were not using condoms. Such sexual behavior, hence, facilitated the transmission of HIV infection from the prostitute community into the general public since such clients were likely to have other sexual partners or even wives elsewhere.
A high dependence rate was also observed among the majority of sex workers, with a mean number reported to be 3 persons including their children. This would increase the likelihood of a risky behavior in order to meet the day-to-day demands of their large families whom they supported. It was, however, not established how all these dependents were related to the sex workers.
Knowledge about sexually transmitted diseases was high. There was also high knowledge about the various STD syndromes, namely, those causing discharges, genital ulcers and swellings, skin rashes and abdominal pain. However, the frequency of each of the separate signs and symptoms mentioned was relatively low. The major sources of information about STDs were mainly friends, relatives and radio. Sex workers also discussed STD issues mainly with friends. This implied that peers played a big role in passing on information to their friends. Peers constituted a potential resource that could be utilized in HIV/AIDS interventions through training and use of peer educators.
Almost half of the sex workers (45%) had contracted a sexually transmitted disease giving an indication that unprotected sex with multiple partners was highly prevalent among prostitutes. This also implied a high risk to HIV/AIDS since STDs, especially those causing genital ulcers, are known to be co-factors in the transmission of HIV infection. The commonest STD symptoms contracted were, vaginal discharges and genital ulcer. The mean number of STD episodes suffered in the past one year was 2.5 per sex worker.
Most sex workers sought STD treatment mainly from a hospital or private clinic. Katanga slum area is located in the neighborhood of Mulago hospital, the national referral hospital. Also in the neighboring suburbs of Wandegeya shopping center and Bwaise are a number of clinics which have sprang up to cater for the health needs of the surrounding population who do not want to line up in the long cues in the big hospitals. Qualified personnel man many of these clinics. 25.2% or a quarter of the sex workers occasionally received self-medication from shops or local herbs. This may be one of the reasons for the continued existence of STD in this community due to some prostitutes receiving improper treatment.
It was also observed that 69% of the sex workers continued with risky behavior even when they had an active STD infection, which, as mentioned earlier put them at a high risk of HIV infection and also easy transmission to their clients. Only 31% or a third abstained from sex during this period.
In Uganda, since 1987, a number of HIV/AIDS control activities initiated and implemented by the Government and Non-governmental organizations have been taking place. However, none of these programs has specifically targeted sex workers as a high-risk community in Kampala city. Sex workers have been perceived as incorrigible transmitters of HIV/AIDS who are inaccessible to most program implementers, and most efforts have been directed to protecting men from the prostitutes. Since, in many African traditions, prostitution is in disaccord with traditional values, many programs have tended to marginalize them. Therefore, as revealed in this study, the major sources of information about HIV/AIDS were mainly peers and the radio. Since most of the peers are of low level of education, it is doubtable that they could pass on correct information to their friends. A lot of IEC information on AIDS has been disseminated through pamphlets and leaflets which many of the sex workers cannot read. Sex workers had also made a lot of effort to get information through the radio. Whereas many sex workers may not afford to have a radio set, it is also true that many of these radio broadcasts are mostly brief and lacking in detail, and often not aired in their vernacular dialects for their easy appreciation. They also provide a one-way communication without giving them the chance to ask on some of their concerns. There is thus a need to put in place programs that specifically address the special needs of sex workers in consideration of the special factors that make them vulnerable to HIV/AIDS.
Factual knowledge about HIV/AIDS was high, especially knowledge about HIV/AIDS transmission, the symptoms of AIDS and the asymptomatic nature of infection with the AIDS virus. Most were also aware that presently there is no cure for HIV/AIDS. Knowledge about AIDS prevention has increased due to the many preventive campaigns that have been intensified over the last decade in Uganda.
Sex workers are involved in risky practices to HIV/AIDS through sex networking and commercial sex work. Many had started sex work at an early age, mean age of first sex encounter was 14.7 years and the mean number of clients was 2 per day. 84.2% of the sex workers had regular non-paying partners as well as paying clients. This provided an entry point for HIV/AIDS transmission to the public since they are unlikely to use condoms with regular or steady partners.
Sex workers revealed a number of reasons why they were engaged in paid sex, many of which underscored the centrality of economic need to prostitution. Many lacked financial support for reasons such as death of parents or husbands, divorce or dropping out of school, and unemployment. Therefore, any intervention among sex workers should recognize how integral economic factors are to prostitution, as this needs to be addressed before they can abandon sex work or even adopt safer sex practices.
Men from all walks of life were clients to the sex workers, depending on where the sex worker operated. These included businessmen, professionals, bar-men and bar-owners, white men and students, including men resident in Katanga or from outside. Thus, sex work clients are part and parcel of the general public, and are not very easy to identify, but probably play a big role in the transmission of HIV/AIDS between the prostitute community and the general public. Most sex workers accepted any client as long as he had money to pay for sex.
Sex work transactions were made in various ways. Most clients paid cash while others bought food, paid bills like house rent, school fees, medical bills and others. Others bought sex workers dresses or paid for hairdressing. Since men residing in Katanga could not afford to pay high fees, many sex workers were also engaged in other trade in bars, hotels, discotheques and streets in order to raise more revenue.
Knowledge about condom and its uses was high, again mainly received from friends and the radio. However, accurate knowledge about condom use was lacking although some sex workers knew about which precautions to take before using a condom.
It was also worrying that up to 30% or a third of sex workers had never used condoms in their practice despite having multiple sexual relations. Even among those who had ever used condoms, less than half (41/7%) has used them all the time. Whereas most of the sex workers were aware that condoms could protect them from STDs and HIV/AIDS and unwanted pregnancy, most of them had not taken heed of this knowledge. Not surprisingly, high STD prevalence and fertility indices were observed in this study. It was also observed that on many occasions, it was the sex workers who took the initiative to suggest condom use, made the necessary decision to use condoms, provided the condom and in some cases went ahead to fit the condom on the clients' penis while the clients took a passive role. This evidence that clients, not prostitutes, were refractory to condom use confutes the view that prostitutes are incorrigible transmitters of HIV/AIDS.
Most sex workers (58.6%) kept condoms in their houses in various places which ranged from suite cases, hand bags, cupboards to pillowcases. Most sex workers disposed off used condoms safely in places like the pit latrine, or by burning them or burying them, although a few just threw them in open drainage channels or open rubbish pits where they could pose a health risk. Condom promotion activities should also emphasize the areas of correct storage and disposal just as it puts emphasis on correct usage.
Condoms were readily available to the sex workers through various outlets such as shops, clinics, hospitals, friends and social workers at a reasonable cost when they needed to use them despite a low-grade condom promotion policy in Uganda. Sex workers also played a big role in accessing condoms to their peers in the form of petty trade. Most sex workers expressed that the cost of condoms or their accessibility were not significant factors that contribute to the failure of their use among prostitutes. Almost all sex workers (96.4%) paid for condoms and the majority (81.5%) felt they got enough supplies for their needs.
It was also noted that widespread misinformation about using condoms had been disseminated that could deter many sex workers from using condoms. These included allegations that condoms stick in the vagina or uterus and removing them could involve a major operation,; condoms bursting, condoms having holes and thus not being protective or causing vaginal or abdominal pain. However, it was observed that the majority of the sex workers had never experienced any of these problems in practice.
It was also revealed that clients played a major role in the failure of consistent condom use among sex workers. Many of the sex workers (66.9%) reported incidences where clients on the other hand refused using condoms. Thus, since on many occasions it is the clients who are refractory to condom use, condom promotion among sex workers should include strategies of handling clients who refuse to use condom. They should also emphasize strategies that do not require consent of the client such as the promotion of female condoms.
Most sex workers perceived their high risk to HIV/AIDS infection, judging from their present sexual behavior. 56.9% felt they could easily get infected with the AIDS virus, since they were not using condoms; were having multiple sexual relations; their partners were not faithful; while others doubted the efficacy of condoms in protecting against the AIDS disease. The majority (62.5%), however, thought they might not yet be infected, although it was observed that they had not taken any serious safeguards against the infection. Thus, whereas sex workers perceived their risk to HIV/AIDS, they had not taken serious safeguards to protect themselves from HIV infection. Many sex workers perceived having one faithful partner and using condoms as a safer practical option. A few sex workers had resentment over these options claiming that they had after all got infected while others believed that condoms could not always be perfectly used.
The HIV/AIDS scourge had significantly affected the sex work community in Katanga slum area. Morbidity and mortality rates from HIV/AIDS were high as almost all (98%) of the sex workers reported knowing someone with AIDS in their community. This was supported by the observation that risk behavior was rampant in Katanga slum area. A number of sex workers (44.8%) had received counseling on HIV/AIDS before, although only 15% had made the decision to have an AIDS test. Impact was reported on individual sex work practice in various ways. Some sex workers were now making an attempt to use condoms because of fear of contracting AIDS, and others had reduced the number of their clients. Others reported to be selective among their clients and were now compelled to do sex work because they had no other options of financial support for themselves and their families apart from paid sex. 63.1% had reduced the number of their clients to a level just sufficient for survival. Most of the sex workers had reduced their clients beginning in late 1994, a trend that has also been reported in the National HIV/AIDS surveillance reports. These reports on behavior change contend with others that have been gathered nationwide.
A number of AIDS control activities have been initiated and implemented among women in Katanga slum area. However, coverage was limited, since a large proportion of the community is illiterate or semi-literate, and could not read or write. Not surprisingly, most sex workers received their information about STD and HIV/AIDS mainly from friends and the radio. It was also observed that those who participated in these activities had learnt several lessons, particularly regarding condom use, behavior change through partner reduction and facts about HIV/AIDS.
Sex workers thus proposed that there was a need for more education, especially on condom use. Some sex workers also suggested future interventions involving creation of job opportunities or income-generating activities to offer an alternative to sex work. A number of sex workers expressed their willingness to participate in AIDS prevention activities through teaching and counseling their peers, exemplary behavior by opting for behavior change, participating in AIDS seminars and distributing condoms.
