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Stanford University School of Medicine

Sex work in Uganda: Risky business

We step across a sewage channel to enter an unmarked, tin-roof building, leaving the bright sunlight for the dark corridors of a 23-room inn in a busy commercial district in Kampala, Uganda. More than a dozen women huddle on the mud floor in a small rectangular courtyard whose walls are charcoal-black. We gradually come to realize that we’ve arrived at a brothel, the destination for our field tour with the Women’s Organization Network for Human Rights Advocacy, a prominent group that fights for the rights of Uganda’s sex workers.

One woman in her 30s, dressed in a black head scarf, does much of the talking for the women at the brothel, speaking in her native Luganda while the manager of the inn translates. The woman says she lost her husband and had no source of income to support herself and her children. “I almost committed suicide,” she says, but a friend encouraged her to try sex work to earn money. “My friend said, ‘I will show you what to do.’” Behind her, three wooden doors lead to squalid, closet-sized rooms where the women live and work their trade.

The women, we learn, have turned to sex work as a matter of survival. Many have lost husbands or partners on whom they depended for income, and they lack the education or skills to find other jobs that pay a livable wage.

“If they turn away from sex work, how will they feed their children or pay their school fees?” one WONETHA official says.

But the work comes with a price. The women frequently face client abuse, beatings and harassment on the streets, even police brutality – including rape, beatings and extortion – and the ever-present risk of HIV.

“Sex workers are facing a health and human rights crisis in Uganda. Despite this, little is being done to protect the most basic human rights of sex workers,” declares a pink banner at WONETHA’s headquarters in central Kampala.

The largest organization of its kind in East Africa, the group works to provide the women with better access to medical care, legal and social services, job training and freedom from violence and arbitrary arrests.

I met with members of the nonprofit group in February as a Global Justice Fellow with American Jewish World Service, an international development organization that aims to end poverty and promote human rights in the developing world. I was among 15 fellows from the Bay Area who spent nine days in Uganda learning about the work of human rights organizations that advocate for women, girls and the LGBT community.

One of WONETHA’s goals is helping prevent HIV among the sex workers and obtain access to medical care for those who are infected with the virus. Sex workers are the greatest at-risk group in the country, with an infection rate of 37 percent in 2010, according to the Uganda AIDS Commission.  At the national level, Uganda was particularly hard-hit by AIDS early on, with the disease reaching epidemic proportions in the 1980s. Between 1992 and 2000, however, there was a dramatic decline in incidence – from an estimated high of about 18.5 percent to 5 percent. In recent years, the number of infections has begun to rise again in what many see as a disturbing trend; the infection rate reached 7.2 percent in 2012, according to the United Nations Joint Programme on HIV/AIDS.  Lax attitudes regarding safe sex and a lack of condom use are among the factors cited in the trend.

WONETHA distributes condoms to help protect sex workers against HIV and other sexually transmitted diseases. A dozen large boxes of Chinese-made condoms, supplied by the United Nations Population Fund, occupied a cool space in the group’s headquarters on the day of our visit – some 100,000 of them ready to be distributed to various locations around town.

But condom use, we are told, is not always guaranteed. Clients may resist using them or pay more for a condom-free encounter. A program manager with the group told me that even in marriages, many men resist use of condoms but continue to have multiple partners – putting their wives and the other partners at risk.

“If you have no food, you are not able to negotiate for a condom,” she said. “If you are dependent on your husband or partner, you can’t negotiate for safer sex. In our culture, the man determines when, where and how you have sex.”

The organization has effectively lobbied the government to obtain better access to medical services for sex workers, who may face discrimination by caregivers at hospitals and clinics, said the group's executive director. She said in 2007, when she sought antiretroviral treatment for HIV, she was told she would have to wait until someone else died. She suffered with serious weight loss, skin rashes and low T-cell counts, the key immune cells that fight off infection. Now on medication, she is doing well.

Before 2010, she said, Uganda's national AIDS prevention strategy did not target  sex workers or address their needs, even though they are a high-risk group. This made it difficult for them to obtain medical care and other services. But that has changed, in part because of pressure from WONETHA.

“We are seeing sex workers access services, and that is huge,” said the executive director, who has been invited to delivery a plenary address on sex work at the International AIDS Conference in July in Australia.

WONETHA officials also have been actively working to counteract a pattern of brutal treatment by police of sex workers (prostitution is illegal in Uganda).

Police rape and extortion are common, the women say, with officers demanding as much as $100 - the equivalent of more than two weeks’ pay. “The police will kick you on the ground, beat you, put you on TV to embarrass and shame you,” says the woman at the brothel, as her fellow workers nod in agreement.

WONETHA officials have been working with the police to help change attitudes, with some success. In some locations, police now patrol the brothels to provide protection, not to harass sex workers.

The sex workers, meanwhile, say they yearn for a better life for themselves and their children. WONETHA offers literacy classes for those who can’t read or write, as well as training in computer and vocational skills, so that the women can find other jobs.

“We really believe someday we will leave this work,” one woman said.

As for their children, “We want to educate them. We don’t want them to be like us.”

Previously: In Uganda, offering support for those born with indeterminate sexNo clowning around: How clown-educators are increasing HIV awareness in Guatemala and Guatemalan syphilis study: NIH and CDC directors’ commentary

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