HIV/AIDS is a major health problem in Uganda. According to the National AIDS Control Programme (ACP surveillance report), as of late 1996, more than 1.5 million people had been infected with HIV/AIDS. A decade ago, women seemed to be on the periphery of the epidemic. Today, they are at the center of concern. ACP estimates that more than half of the newly infected adults are women. This means that the number of women newly acquiring HIV/AIDS each year cannot be counted in the hundreds or even the thousands. Among women, the hardest-hit group is the youth who engage in risky practices such as commercial sex (WHO/GPA/94). AIDS Control Programme estimates that half of all HIV/AIDS infections in Uganda to date have been among those 15-24 year old, with female to male ratio of 6:1. Surveillance data on AIDS from several parts of Uganda suggests that young women under 25 years account for more than 30% of female AIDS cases. Many of the commercial sex workers fall in this age group. Throughout Uganda, and Africa in general, heterosexual intercourse is the predominant mode of HIV/AIDS transmission (Plummer 1988). People who engage in unprotected sex with many partners such as commercial sex workers are especially at high risk. The result is a growing AIDS burden among prostitutes. Today, many young women rely on prostitution or sex work for economic survival. The proportion and the number of women who do so are often directly related to the economy and level of unemployment. Prostitution is illegal in Uganda and therefore, underground. This means that prostitutes may have to work without adequate control over the conditions of sex work transactions (Bakwesegha 1982). As in many societies, many women in Uganda still face discrimination in education, employment and social status resulting in economic vulnerability to HIV/AIDS. This includes discrimination that girls face in both educational institutions and the family, occupational segregation in low paying clerical and service jobs, and lack of access to technical assistance, training and credit (WHO/GPA/94). All these cause women to end up in commercial sex work for survival. Rural-urban migration and civil wars, which Uganda experienced in the past, also led women to engage in prostitution and increased their vulnerability to HIV/AIDS through rape, other forms of sexual abuse and forced sex work (Bakwesegha 1982). There was, therefore, a need to study the knowledge and sexual behavior patterns of commercial sex workers in Kampala related to HIV/AIDS and come up with appropriate interventions. There was also a need to study the factors that lead young women to engage in sex work in the wake of the HIV/AIDS scourge.
The study was carried out in the Katanga peri-urban slum area located 3 km northwest of Kampala, the capital city of Uganda. Over 15,000 people of different gender, age and ethnic background inhabit Katanga slum area. Like many other slums, it attracted many rural-urban migrants, most of whom are school dropouts, and many out of school female youth. The high population density led to poor socio-economic conditions, poor housing and sanitation. Sources of income are not only limited but also unpredictable. Because of limited income, amidst unlimited needs, most of the young women in Katanga engage in prostitution as a major means of survival. The consequence has been a high fertility rate and prevalence of sexually transmitted diseases, including HIV/AIDS. Despite the fact that prostitution is illegal in Uganda, Katanga has remained well known for sex trade in Kampala city. The problem has not only been poor enforcement on prostitution but also lack of information on sexual behavior patterns and vulnerability factors among these women to commercial sex and HIV/AIDS infection. This study addresses these issues.
HIV/AIDS has hit Uganda hard. After years of civil strife and devastation, the country is working hard to recover. The AIDS pandemic not only strains the already strained economic and social systems of the country, but also diverts the financial and human resources from rehabilitation of its infrastructure and productive enterprises. Women, especially sex workers, are at the center of the epidemic because of the cultural and social-economic factors that make them especially vulnerable to HIV/AIDS. Up to 30% of women attending antenatal clinics are HIV/AIDS infected. HIV/AIDS prevalence of more than 50% is reported among some groups of commercial sex workers, with rates 15-20% among STD clinic attendants. Despite all these facts, limited in-depth research had been undertaken to examine the knowledge and sexual behavioral patterns related to HIV/AIDS among commercial sex workers in Kampala, which were in most cases the reservoirs and source of the infection to the general public.
This study was designed to answer the following research questions:
· What were the factors that led to commercial sex work among women dwelling in Kampala slum areas?
· What actual knowledge did commercial sex workers have about HIV/AIDS? Was it useful knowledge? Did they have knowledge about the more relevant protective options?
· Were commercial sex workers engaged in unprotected sex? To what extent and under what circumstances? What was the role of condom availability in protection against STD and HIV/AIDS?
· Did commercial sex workers perceive their risk of getting HIV/AIDS? Which ones and to what extent?
· Have they adopted any safe sex practices in the wake of the deadly AIDS? Which ones and to what extent?
· What are the best intervention strategies among commercial sex workers?
1.4.1 Purpose
The overall goal of this study is to determine the knowledge and behavioral patterns related to HIV/AIDS among commercial sex workers living in the Kampala slum areas. Ultimately, the study sought to provide information on what intervention methods were necessary for protecting commercial female sex workers from HIV/AIDS infection.
1.4.2 Specific Objectives
· To establish factors leading to prostitution among commercial sex workers in Kampala slum areas.
· To determine the commercial sex workers' knowledge about HIV/AIDS, especially knowledge on protective options.
· To assess the perception of risk to HIV/AIDS infection among commercial sex workers in Kampala slum areas.
· To establish the sexual behavioral practices and adjustment (if any) to HIV/AIDS among commercial sex workers.
· To establish the patterns of condom use and role of condom availability in protection against STD and HIV/AIDS among commercial sex workers.
· To make recommendations on the best intervention strategies against HIV/AIDS among commercial sex workers.
The weak position of women in society is reflected in the fast spread of HIV/AIDS among women, and especially young women. The sexual and economic subordination of women fuels the HIV/AIDS epidemic in Kampala among commercial sex workers. In order to break the cycle of neglect which affected commercial sex workers in their life span and across generations, it is essential to undertake action-oriented research, to provide the missing information that would enable commercial sex workers to make informed choices and to improve the quality of their lives. Given the growing dimensions of HIV/AIDS, they have often been stigmatized and blamed for "causing" HIV/AIDS and other STDs. They have frequently been identified as "reservoirs of infection" or as "vectors of transmission" to their male partners (clients) and their offspring. This inaccurate view had been misleading, as it had prevented research and programs from developing services which met the needs of these sex workers. It also underlined some research and intervention strategies which had been designed more to protect men from women, rather than to enable the sex workers to protect themselves. In Uganda today, authorities either continued to deny that prostitution existed in society, or alternatively minimized its scope. To be able to have interviews with several hundreds of prostitutes was a persuasive response. Also, scholars sometimes unjustifiably doubted whether it was possible to identify prostitutes and enroll them in research. Indeed, this pilot study carried out among prostitutes in Katanga slum area, helped dispel such a viewpoint. In Uganda until now, research had not paid attention to the vulnerability factors that led women to prostitution or commercial sex work. Furthermore, research had not examined the knowledge and sexual behavioral patterns related to STD and HIV/AIDS among commercial sex workers, as they were a marginalized group. There was also limited information on the important area of prostitute sexual behavior, risk perceptions and practices, and this study sought for this needed information.
HIV/AIDS has confronted many countries as one of their severest local problems. The depopulation of rural areas and migration to work in cities has led to the disruption of family structures, commercialization of sexual relationships and an increase in infection. Commercial sex work constitutes a socio-economic issue that many scholars of human behavior tend to shy away from for reasons ranging from subjective sentiments to strict observation of ethics or morals (Bakwesegha 1982). Although considered a dirty profession by many reputable scholars and scientists, prostitution lends itself to be a fascinating, perplexing and bewildering field of social relations. Our stubborn refusal to investigate into this subculture of our society does not only reflect an unjustified refusal to understand, correct or reverse, and improve regressive instincts of human development, but also reflects on our unfortunate attempt to treat a patient whose disease we really know but have not bothered to diagnose in the first place. Prohibition of commercial sex work and prosecution of sex workers has not contributed towards the willing co-operation of groups who could play an important role in the slowing down of the dissemination of infection. The phenomenon of prostitution became of particular interest to the researcher not only because of the so many educated and uneducated young women in Kampala who had fallen victims to it as an impulse of how Uganda's traumatic economic transformation has manifested itself, but also on the important consideration of how integral HIV/AIDS infection, spread and control in Kampala city was to this phenomenon. Prior to the advent of HIV/AIDS, there was very little academic literature focusing on prostitution (Pyett 1996). In the last decade, concerns about the potential of HIV transmission between prostitutes and their clients and ultimately to the general population, have stimulated a considerable amount of research in this area. However, behavioral research relating to prostitution and risk practices for HIV infection and other sexually transmitted diseases (STDs) have been given little attention in Uganda. Among the women, the hardest-hit groups by HIV/AIDS are the youth, especially commercial sex workers (WHO/GPA/DIR/94.4). The AIDS Control Programme of Uganda estimates that half of all infections in Uganda to date have been in 15-24 years old (ACP surveillance report 1996). However, the peak age of infection in Uganda is lower in girls than boys, presumably because girls are more prone to sex work or sex net working than their male counterparts (Rwabukwali 1990). 60% of all the new HIV infections are among 15-24 years old, with female to male ratio of 6:1 (ACP 1995). An analysis of surveillance data on AIDS from several parts of Uganda suggests that young women under 25 years accounted for nearly 30 % of female AIDS cases (ACP surveillance report, 1995). Most of the female sex workers fell in this age group. As many as one in three pregnant women attending antenatal clinics in Ugandan urban centers such as Kampala city were HIV infected (ACP surveillance report 1994). Throughout all of Uganda and Sub-Saharan Africa in general, heterosexual intercourse is the predominant mode of HIV transmission (Plummer 1988). The result is a growing AIDS burden among women. People who engaged in unprotected sex with many partners such as prostitutes and their clients were especially at high risk (Ngugi 1988). Today, many young women rely on prostitution or sex work for economic survival. The proportion and the number of women who do so, is often directly related to the economy and level of unemployment. Prostitution is illegal in Uganda and underground, which means that prostitutes may have to work without adequate control over the conditions of sex work transactions (Bakwesegha 1982). Like in many societies, many women in Uganda still face discrimination in education, employment and social status resulting into economic vulnerability to prostitution and HIV/AIDS. This included discrimination that girls face in both educational institutions and the family, occupational segregation into low paying clerical and service jobs and lack of access to technical assistance, training and credit. All these forced women to end up in commercial sex work for survival. Civil wars and strife, which Uganda experienced in the past, also led women to engage in prostitution and increased their vulnerability to HIV/AIDS through rape, other forms of sexual abuse and forced sex work. Any such non-consensual penetrative sex carried a risk of transmission of HIV/AIDS and STDs, particularly as men who raped were not likely to use a condom. While the proportion of girls who engaged in prostitution varied in different socio-economic setting in Kampala, it is known that prostitutes constituted a sizable population of young women in the city (Bakwesegha 1982). Very little information was available concerning the large number of prostitutes who worked in the various sections of the sex industry. Obstacles to safe sex practices at individual, organization and societal levels existed. Within the sex industry, such obstacles varied as a result of the range of organizational and individual practices in the sex industry as well as the different legislatures (Campbell 1991; Jackson 1992). The type of prostitution involved in is likely to affect risk practices as well as the range and frequency of sexual services provided to clients (Jackson 1992). There was, therefore a need to study the knowledge and behavior patterns of prostitutes related to HIV/AIDS in Kampala slum areas to recommend appropriate interventions. There was also a need to study the vulnerability factors that led these women into sex work.
In Kampala, one can identify more than four categories of prostitutes (Bakwesegha 1982) namely, indoor prostitutes residing in Kampala areas. The most notable areas of these include Kisenyi, Katwe, Kibuli, Kamwokya, Nakulabye, Mulago and Katanga. The second category of prostitutes is the bar-prostitutes. These were women who frequented bars, lodges, hotels and discotheques with the hope of meeting their potential clients in these localities. The third category of prostitutes in Kampala consisted of bar maids. These were women employed as bar maids on a regular basis to serve drinks, etc. in the bars, and they were paid as such. Their terms of employment did not in any way include prostitution. However, customers knew that these bar maids were also prostitutes. The fourth category of prostitutes in Kampala was the street light/red light prostitutes. These were women who dressed up meritoriously and went and stood at strategic points such as along major streets like Nile Avenue, near hotels like Speke Hotel, near taxi and bus stops, near discotheques, usually under street lights waiting for potential clients.
In between these major categories fell the various subtle but existing categories such as the affluent prostitutes, "the sugar mommies" and "sugar daddies", the volunteer bar maid prostitutes that normally existed at times of economic boom, the high class street-light prostitutes who walked idly along streets in high class residential areas like Nakasero and Kololo and some students in tertiary institutions such as Universities and Colleges. This pilot study limited its scope to indoor prostitutes residing in slum areas.
