Key populations at increased risk of HIV

Although Uganda’s HIV epidemic affects all population groups, there are populations that are more at risk for HIV infection and therefore bear a disproportionate burden of HIV.

These key populations include men who have sex with men (MSM), sex workers and their clients and partners, fisher folk; and people who inject drugs.

Recent studies have found HIV prevalence (the number of people living with HIV at a given point in time) of 33-37 per cent among female sex workers, 18 per cent among partners of sex workers, and 13.7 per cent among MSM.

In Rakai District, a recent survey has found HIV prevalence of 41 per cent at Kasensero landing site and 19 per cent in the surrounding communities.

It should be recalled that the first HIV/Aids cases in Uganda were identified in 1982 at Kasensero and Lukunyu landing sites on the shores of Lake Victoria. It is therefore alarming that HIV prevalence is still as high as 41 per cent at these sites, thirty years after the first cases were identified.

Evidence shows that HIV incidence (the number of new cases of HIV infection occurring in a population that was originally not infected with HIV) is equally high among key populations than in the general population.

A recent study among the fishing communities of Lake Victoria in Uganda found HIV incidence of five new HIV cases per year for every 100 people tested, while another study done at Kasensero landing site in Rakai District found HIV incidence of four new HIV cases per year for every 100 people who were tested for HIV.

Studies conducted among female sex workers and MSM have indicated similar levels of high HIV incidence.

In Rwanda, one study found HIV incidence of four new HIV cases per year for every 100 female sex workers who were not originally infected with HIV, while a study among MSM in Mombasa found HIV incidence of seven new HIV cases per year for every 100 MSM who were not originally infected with HIV. These findings suggest that key populations have high levels of both HIV incidence and prevalence, and constitute a key population that we cannot afford to ignore in our HIV prevention efforts.

Multiple sexual partnerships
Key populations are linked to the general population and HIV prevalence in the general population cannot be successfully reduced unless interventions are also targeted at these groups. A study of MSM in Kampala, Uganda found that nearly four in 10 people reported that they have both male and female partners.

A recent study conducted jointly by Makerere University School of Public Health and Centers for Disease Control and Prevention (CDC) found that almost one-third of MSM had been married and 20 per cent were currently married.

In another study, female sex workers (FSWs) reported an average of 28 partners in the past 30 days while truckers reported an average of seven partners over the same period. Only 21 per cent of truckers and 45 per cent of FSWs reported using condoms consistently.

A study conducted in 46 fishing communities of Lake Victoria found that 11 per cent of women and 46 per cent of men reported more than one sexual partner in the past year. However, condom use was only 41 per cent among women and 47 per cent among men.

Among MSM, only 40 per cent were found to have used condoms with their female casual partners, 39 per cent with female steady partners, 43 per cent with male casual partners and 50 per cent with their male steady partners in the past three months. These findings suggest that these key populations are at an elevated risk of HIV infection.

Need for increased focus on key populations
Despite engaging in high risk sexual behaviours, key populations have been largely neglected in Uganda’s HIV prevention response. While the revised National HIV and Aids Strategic Plan (2011/12-2014/15) includes specific targets for key populations, only targets for female sex workers, fisher folk and truckers have been given attention at the expense of other key populations such as the uniformed services, injecting drug users, and MSM. Given their continuous interaction with members of the general population, interventions targeting key populations at increased risk of HIV infection can contribute to the reduction in HIV incidence by 30 per cent by 2015, as stipulated in the National HIV Prevention Strategy.

These interventions should include adequate access to HIV counselling and testing services, sexually transmitted infections treatment, condom promotion and supplies, including condom lubricants; and appropriate linkage to HIV care and treatment services, and male circumcision.

Challenges of providing HIV services to key populations
Improving access to HIV services among key populations at increased risk of HIV infection is largely hampered by lack of information, stigma, weak linkages between health facilities and programmes, stock-outs of ARVs, understaffing at health facilities, limited health centre accreditation to offer ARV Therapy [ART], and the migratory nature of some key populations such as the fishing communities and female sex workers.

The migratory nature of the fisher folk makes it difficult and expensive for programmes to reach them, and has been associated with increased sexual mixing coupled with high levels of alcohol use and involvement in casual sexual relationships. Because they usually reside in hard-to-reach areas, fishing communities are rarely accessed by service organisations. As of June 2012, just 15 per cent of 6,225 fisher folk in need of ARVs were receiving it, according to the Uganda Aids Commission (UAC).

Female sex workers are also fairly mobile, making it difficult for programmes to target them. Others tend to practice sex work at night but engage in other forms of employment during the day, thereby making it difficult to isolate them from other women.

Programmes that have tried to target them have reported high levels of reluctance to utilise HIV prevention, treatment and care services, thereby putting their health in jeopardy. This observation is confirmed by preliminary results from a multi-site research that is being conducted among high-risk uninfected female sex workers in Uganda, Kenya, Tanzania and Thailand.

Preliminary results from Uganda’s arm of the study showed that 35 per cent of sex workers tested HIV-positive, but a large number did not return for confirmatory tests. Failure to return to get confirmatory results and access to care is a lost opportunity for HIV prevention and a potential source for new infections among clients and partners of sex workers.

In Uganda, as well as in many other African nations, prostitution is criminalised and sex workers may face a prison sentence and fines. The illegal nature of their work makes it difficult to access treatment for HIV. Additionally, these marginalised women face discrimination and some health workers may be reluctant to provide prevention or treatment services to them.

Men who have sex with men are a highly stigmatised group in Uganda and other countries in sub-Saharan Africa, and because of this; they are not easy to identify for targeted HIV prevention interventions.

Although MSM desire and seek professional medical care from facilities such as clinics, hospitals, and health centres; in most cases, they are strongly ostracised. One study among MSM in Kenya found that majority of them felt that they are not treated as other people when they try to access health care services.

“There was this one, she said to me why I am behaving like a girl and what must she write on my file, a male or a female?...I felt bad, but I asked her how can she say that because this is who I am and it is my life, what was she going to do if I was her child? And she said she will never have a child like me! So I said she must leave me alone and do what she is here for”.

A study conducted by the Population Council in Nairobi, Kenya, in 2006 found that MSM do not approach providers for specific advice, as they fear exposure to the legal system since homosexuality is illegal in Kenya, or fear that providers will discriminate against them. Also, widespread stigmatisation of sex between men prevents providers from discussing special prevention issues, creating a missed opportunity for prevention counselling targeted to men who have sex with men.

Evidence suggests that existing structural barriers, including policy and regulatory frameworks such as the proposed Anti-Homosexuality Bill in Uganda, have got the potential to drive MSM further underground, and therefore hidden away from the HIV prevention and treatment services that they need. In addition, health workers may refuse to serve MSM because the Bill proposes severe punishments, including prison, for those who know about them and fail to report them. The danger in this provision is that anyone working with MSM, such as medical doctors and civil society leaders will be intimidated by fear of prosecution. This will greatly jeopardise HIV prevention efforts.

To see a truly effective HIV response, civil society and healthcare providers have to be in a position to be able to work with all marginalised groups and be able to provide stigma-free services.

Conclusion and way forward
Although Uganda’s National Strategic Plan for HIV/Aids (2011/12-2014/15) hopes to increase the proportion of key populations reporting consistent condom use to 80 per cent by 2015, it will be difficult to fulfil this goal if these populations continue to be neglected or persecuted.

The government does not recognise MSM as an at-risk group and the National Strategic Plan is silent about them. There is need to incorporate all key populations into HIV prevention programming, and a need for specific programmes targeting key populations.

Additional interventions to reduce stigma and discrimination are needed and the national HIV/Aids budget should have an allocation for funding of interventions targeted at key populations.

Discriminatory laws such as the Anti-Homosexually Bill or legislation against prostitution are obstacles to HIV prevention and undermine the public’s health, with potentially disastrous effects on HIV prevention.

An HIV/Aids-free generation is a goal for all of us, or it will not be reached by any of us.

The article is authored by Joseph KB Matovu, Rhoda Wanyenze, David Serwadda, lecturers at Makerere University School of Public Health.

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