Social and structural factors increase inconsistent condom use by sex workers’ one-time and regular clients in Northern Uganda

ABSTRACT

While sex workers (SWs) bear the brunt of the epidemic in Uganda, there remains a dearth of empirical research on the structural drivers of HIV prevention among SWs. This study examined the drivers of inconsistent condom use by one-time and regular clients of young women SWs in Gulu, Northern Uganda. Data were drawn from the Gulu Sexual Health Study, a cross-sectional study of young SWs, aged 14 years and older (2011–2012). SWs were recruited using peer/SW-led outreach, in partnership with The AIDS Support Organization and other CBOs. Multivariable logistic regression was used to examine the correlates of inconsistent condom use by one-time and regular clients. In total, 84.5% of the 381 SWs servicing regular clients and 76.8% of the 393 SWs servicing one-time clients reported inconsistent client condom use. In multivariable analysis, physical/sexual violence by clients (AOR = 5.39; 95%CI 3.05–9.49), low sexual control by workers (measured by the validated Pulweritz scale) (AOR = 2.86; 95%CI 1.47–5.58), alcohol/drug use while working (AOR = 1.98; 95%CI 1.17–3.35) and migration to Gulu for sex work (AOR = 1.73; 95%CI 0.95–3.14) were positively correlated with inconsistent condom use by one-time clients. Correlates of inconsistent condom use by regular clients included: low sexual control by workers (AOR = 4.63; 95%CI 2.32–9.23); physical/sexual violence by clients (AOR = 3.48; 95%CI 1.85–6.53); police harassment (AOR = 2.57; 95%CI 1.17–5.65); and being a single mother (AOR = 2.07; 95%CI 1.09–3.93). Structural and interpersonal factors strongly influence inconsistent condom use by clients, with violence by clients and police, low sexual control by workers, migration and single-parenthood all linked to non-condom use. There is a need for peer-led structural interventions that improve access to occupational health and safety standards (e.g., violence prevention and alcohol/drug harm reduction policies/programming). Shifts away from the current punitive approaches towards SWs are integral to the success of such interventions, as they continue to undermine HIV prevention efforts.

KEYWORDS:

• Sex work
• HIV prevention
• condom
• structural determinants
• criminalization

Acknowledgments

We thank all those who contributed their time and expertise to this project, particularly participants, Acholi interview and peer/ sex worker outreach teams, TASO Gulu community advisory board and humanitarian/ refugee, youth, women, and sex work partner agencies. We wish to acknowledge in particular Godfrey Muzaaya, Esther Achan, Josephine Birguni, Monika Akello, Miriam, Katie Muldoon, Jacky Ayat, Beatrice Baraka, Bibian Achan, Grace Lakot, Winnie Amunu, Andrew Mijumbi Ojok for their research and administrative support. This research was supported by a Canadian Institutes of Health Research Team Grant on Gender, Violence and HIV (TVG-115616). PD is the recipient of the Canadian Institutes for Health Research (CIHR) and the Michael Smith Foundation for Health Research (MSFHR) Postdoctoral fellowship awards. KS is supported by a Canada Research Chair in Global Sexual Health and HIV/AIDS and Michael Smith Foundation for Health Research.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by Canadian Institutes of Health Research: [Grant Number TVG-115616].