Open access Original research BMJ Open: first published as 10.1136/bmjopen-2020-043078 on 19 May 2021. Downloaded from Mobility study of young women who exchange sex for money or commodities using Google Maps and qualitative methods in Kampala, Uganda Rachel King ,1 Eva Muhanguzi,1 Miriam Nakitto,2 Miriam Mirembe,2 Francis Xavier Kasujja,2,3 Daniel Bagiire,2 Janet Seeley 2,4 To cite: King R, Muhanguzi E, ABSTRACT Strengths and limitations of this study Nakitto M, et al. Mobility Objectives We aimed to assess mobility patterns and study of young women who reasons for high mobility among young women engaged ► This study investigates behaviour of one of the most exchange sex for money or in sex work within a randomised controlled trial to gauge commodities using Google vulnerable populations to HIV, sexually transmitted how mobility may hinder access to health services and Maps and qualitative methods infections (STIs) and unintended pregnancy in sub- enhance HIV risk in a highly vulnerable population. in Kampala, Uganda. BMJ Open Saharan Africa; young sex workers aged 15–24 Setting Participants were recruited from a clinic in 2021;11:e043078. doi:10.1136/ years. bmjopen-2020-043078 Kampala, Uganda set up for women at high risk of HIV ► This study illuminates detailed factors that motivate infection. young sex worker mobility over time and the po- ► Prepublication history for Participants Adolescent girls and young women engaged this paper is available online. tential relationships between mobility and high-risk in sex for money and/or commodities are at particular risk To view these files, please visit sexual behaviour. in countries with high HIV prevalence and high fertility the journal online (http:// dx. doi. ► This study employed both qualitative and a mapping rates. High mobility increases exposure to HIV risk. Women org/ 10. 1136/ bmjopen- 2020- methodology using Google Maps to explore partici- participants were eligible for the parent study if aged 15– 043078). pants’ own descriptions of distance, frequency and 24 years, HIV negative and engaged in sex work. For this reasons for mobility as well as mapped locations that Received 05 August 2020 substudy, 34 qualitative interviews were held with 14 sex highlight very high levels of mobility giving insight Revised 18 April 2021 workers (6 HIV positive, 8 HIV negative), 6 health worker/ Accepted 22 April 2021 into options to inform better suited interventions. policy makers, 3 peer educators, 5 ‘queen mothers’ and 6 http://bmjopen.bmj.com/ ► The data gathered here are highly contextual and male partners specific to the study population and environment; Measures Participants used Google Maps to identify the findings may not translate to other regions of work venues at 12- month and 18- month study visits. We sub- Saharan Africa or elsewhere. also conducted 34 interviews on mobility with: high- risk ► In this analysis, we have not combined the STI re- © Author(s) (or their women, male partners, health workers and sex- worker sults with the mobility data. employer(s)) 2021. Re- use managers. Topics included: distance, frequency and permitted under CC BY- NC. No commercial re- use. See rights reasons for mobility. We used Python software to analyse and permissions. Published by mapping data. BMJ. Results Interviews found in depth narratives describing sex work based on stigma or relationship on September 24, 2021 by guest. Protected copyright. 1Institute for Global Health lack of education and employment opportunities, violence, status.4 5 In some cases, sex work is the only lack of agency, social, sexual and familial support Sciences, Department of source of family income, and in others, Medicine, University of California networks and poverty as a complex web of reasons for San Francisco, San Francisco, high mobility among young sex workers. women use transactional sex to supplement 6 California, USA Conclusions Young women at high risk are highly mobile. income. Transactional sex may thus be situ- 2 Social Aspects of Health Across Reasons for mobility impact access and retention to health ational or temporary, and associated with the Lifecourse, MRC/UVRI and services and research activities. Strategies to improve acute shortfalls in cash, need for school fees LSHTM Uganda Research Unit, retention in care should be cognisant and tailored to suit 7 8 Entebbe, Uganda or food insecurity. Sex work is often socially mobility patterns. 9 3Department of Epidemiology stigmatising, whereas informal transactional and Biostatistics, School Trial registration number NCT03203200. sex may be socially accepted in some, situ- of Public Health, Makerere ations, or contexts.10 Globally, female sex University, Kampala, Uganda 4 workers (FSW) of all ages are over 10 times Department of Global Health & INTRODUCTION Development, London School of Adolescent girls and young women engaged more likely to be living with HIV than women 11 Hygiene and Tropical Medicine, in sex in exchange for money and/or in the general population. In sub-Saharan London, UK commodities are at particular risk in coun- Africa in 2012, the average HIV prevalence 11 Correspondence to tries with high HIV prevalence and high among FSW was >35%, with 20%–40% of 1–3 Dr Rachel King; fertility rates. Young women may differen- FSW entering sex work as adolescents with a rachel. king@ ucsf. edu tiate between commercial and transactional mean age of entry of 16 years or younger. King R, et al. BMJ Open 2021;11:e043078. doi:10.1136/bmjopen-2020-043078 1 Open access BMJ Open: first published as 10.1136/bmjopen-2020-043078 on 19 May 2021. Downloaded from In Uganda, about 12% of adolescent girls and young screening and treatment, ART and co-trimoxazole/ women report transactional sex.12–14 Young people in dapsone preventive therapy. Enrolled women attended Uganda have an HIV prevalence of 3.7% nationally, yet quarterly visits for HIV prevention and treatment services younger female sex workers have about a four to seven and study visits every 6 months. This clinic generally saw times higher prevalence of HIV,15 16 with female sex about 50 sex workers per day during the time of the study. workers over 15 years of age in Kampala reported to To protect the confidentiality and safety of participants, it have between 33% and 37% HIV infection.17 18 In addi- was located in an accessible area of central Kampala not tion, female sex workers under 16 years of age, new to identifiable to the general public as a place frequented sex work are dramatically more vulnerable than older specifically by participants at high risk of HIV infection. colleagues to violence, sexually transmitted infections (STIs) and HIV and poorer access to services.19–25 Yet, Procedures despite rising numbers of young female sex workers and Mapping of work venues their recognised vulnerability, there have been few inter- The first aim of this substudy was to explore the dynamics ventions to date that have targeted this group.3 25 of the social and sexual networks, mobility and context of Studies in India have found that sex work-related YWHR in Kampala. Work venues of our RCT participants mobility is often undertaken to maximise trade oppor- have been mapped in two ways: qualitative and quanti- tunity.26 In East Africa, research around mobility has tative data collection using key informant interviews of highlighted that mobility both short-term and long- term four categories of participants in urban Kampala: YWHR, was associated with higher- risk sexual behaviour, and is peer educators, sex worker managers and male partners. strongly associated with gender: the HIV risks associated In- depth interviews of YWHR study participants explored with mobility are more prominent for women than for where, why, how, when, how frequently and for how long men.27 they move using interview guides. High mobility increases young female sex workers Participant enrolment exposure to risk.27 28 Mobility can place people in situa- Randomised parent study tions that increase their risk of acquiring STIs, HIV and Participants were recruited from a specialised clinic in other infections.28–31 Studies have reported that mobility Kampala called the ‘Good Health for Women Project’ is associated with concurrent sexual partners which clinic described above. Women were recruited for this further increases risk to HIV and other STIs.32 Studies clinic by field workers who conducted mobilisation activ- from Europe have shown that migrants diagnosed with ities with community peer sex worker-leaders to identify HIV are more likely to present late for treatment and sex workers from commercial hotspots who were then care than nationals.33 Settling into a new place also pres- enrolled at the clinic irrespective of HIV status as has ents challenges and instability affecting finding food and http://bmjopen.bmj.com/ been described by Vandepitte et al.18 All enrolled women medical care34; these include irregular housing status, attended quarterly follow- up visits including comprehen- language and cultural barriers, cost of services, a lack of sive HIV prevention and treatment services described youth- inclusive health policies and accessible services.27 In above. this paper, we report patterns of, and reasons for, young women at higher risk (YWHR) mobility and the poten- Inclusion criteria for our parent randomised trial (ZETRA trial) tial links between mobility and HIV risk among YWHR included participating in a randomised controlled trial (RCT) that HIV- negative women, aged 15–24 years, being sexually aims to assess the effectiveness of a cognitive behavioural active and having engaged in any form of transactional on September 24, 2021 by guest. Protected copyright. and structural HIV prevention intervention (the Zero sex at least once in the last 3 months, agreeing to partici- Transmission (ZETRA) trial) on reducing the frequency pate in intervention sessions and to all study procedures of unprotected sex in Kampala, Uganda.