vulnerability spectrum: Most at Risk Populations (MARPs) settings and characteristics in selected regions of Uganda

**Muyunga T, **Sebulime G., **Kabugo T., **Nnanyunja J., **Amina S., **Okimait D., **Bazongere P., **Aduk E., **Oryongatum G., **Ssekaayi Michael, **Mutyaaba S., **Margaret N., **Beatrice L., **Matovu M.

BACKGROUND: A systematic review of responses from various spaces was carried out in 10 regions of Uganda.

OBJECTIVE: A systematic inquiry into who MARPs are, what MARPs need, who provides services, what is demanded, what are the behavioural characteristics unique to MARPs and other contexts influencing issues of MARPs was conducted between July 2010-August 2011.

 DESIGN:   Conduct Review of literature, Interviews, structured conversation and focus group discussions. Respondents were drawn from; 150 farmer groups, 220 hair salons,  27 landing sites, 27 police posts, 110 cattle/village markets/social spaces, 225 major RH/FP/MH/CS/Health Services organisations,  with leaders and members of 100 FBOs/2200 CBOs/CSOs/Community Groups,  2,550 lower level governments and communities,  with members of 3,000 men/Women groups/settings, in 19,174 trading and urban spaces (Artisanry marts, car dealerships, repair garages, washing bays, food vending kiosks, video kiosks, shopping malls, recreational spaces)  along 6 major trunk roads and 25 other roads leading to rural districts, 250 educational institutes (higher institutions of learning, colleges, senior/primary schools), 100 minorities’ spaces, 72 fresh foods markets, 200 hotels/lodges, 25 housing estate areas ( e.g. Jinja industrial area, Kampala, Gulu, Mbarara, Kasese, Tororo, Mbale), 170 ludo/snooker points, 1,700 storage and parking bays/car-park/boda/lorry/bus-parks in urban settings.

SETTING: Uganda was divided into operational regions: Central, Northern, Eastern, North Eastern, Mid-Western and south-Western and spaces where inquiry was made included: Lower level governments, urban centers, municipalities, towns, market areas, boarder points, social-meeting places, recreational spaces, food vending areas, film kiosks, shopping malls, parks, washing bays, road stop spots, educational institutions and CSOs. 5 lakes were visited to generate understanding of fisher folk communities.

RESPONDENTS: Key informants mobilised to included; leaders, community members, PLHIV, MSM, Substance users, sex-workers, fisher folk, key persons at road stop spot, bar-owners, informal sector, car-parks, bus-parks, work-place-exit points, school leaders, out-door games’ organizers, and uniformed services.

INTERVENTIONS:  The police and criminal justice system are points for violence redress.  Other forms of Violence/stigma counselling centers exist in major towns/municipals; public and private health facilities provide treatment and management of HIV/STIs; CSOs and government social services’ departments have planned programmes targeting MARPs.

MAIN OUTCOME MEASUREMENT: MARPs character and vulnerability spectrum in Uganda.

RESULTS: At community of residence level right through the Criminal justice system, substance users, MSM, Sex-workers and PLHIV still face stigma and violence.  Sex-work (female, male and child sex-work) is rampant along all major road trunks and in major destination towns towards Uganda’s boarders. Education and housing areas have high prevalence of male/female sex-work, same sex practices and substance use. Violence/stigma counselling centers exist in major towns/municipals; public and private health facilities provide treatment and management of HIV/STIs; CSOs and government social services’ departments have planned programmes targeting MARPs. Key affected populations such as MSM and substance users being criminalized still lack focused programmes targeting them. Communities still do discriminate and stigmatize Key affected populations such as PLHIV, MSM and substance users. There is a tendency to box MARPs issues into HIV Programmes and this has influenced the approach to most programming. Messaging to eradicate risks to HIV should factor in fact that substance use, unprotected anal sex, female sex-work, male sex-work, child sex-work are interconnections in sexual networks

VULNERABILITY:

CENTRAL REGION: This includes Buganda. The MARPs characteristics range from substance use, child sex-work, fisher folk, MSM, LGBTIQQ, male/female sex-work, PLHIV, young people who are sexually active, long distance drivers, and uniformed services. Vulnerability was around; quick mobility, fear of consequences of visibility, stigma, sexual practices, gendered sexual beliefs and the gap between haves and have nots.

EASTERN REGION: These included; Busoga sub-region, Bugwere, Bugisu, Busia and Kapchorwa. The MARPs characteristics range from substance use, child sex-work, fisher folk, MSM, male/female sex-work, PLHIV, young people who are sexually active, long distance drivers, and uniformed services. Vulnerability was around; female genital mutilation, unprotected sex following circumcision period, quick mobility, fear of consequences of visibility, stigma and gendered sexual beliefs.

NORTH-EASTERN REGION: These included; Karamoja sub-region. The MARPs characteristics range from substance use, child sex-work, PLHIV, young people who are sexually active. Vulnerability was around; quick mobility, displacements arising from landslides, floods during rainy seasons, searching for pasture during dry-spells, child abandonment and child neglect.

MID-WESTERN REGION: These included; Bundibugyo, Kasese, Hoima, Buliisa and Fort Portal. The MARPs characteristics range from substance use, child sex-work, fisher folk, MSM, Indigenous Tribes, male/female sex-work around mining and cement industry, PLHIV, young people who are sexually active, long distance drivers, and uniformed services. Vulnerability was around; perceptions of men about mid-Western Uganda females, girl-child elopement, quick mobility, fear of consequences of visibility and stigma.

SOUTH-WESTERN REGION: These included; Kabale and Ankole Sub-region. The MARPs characteristics range from substance use, child sex-work, fisher folk, MSM, male/female sex-work, PLHIV, young people who are sexually active, long distance drivers, and uniformed services. Vulnerability was around; quick mobility, fear of consequences of visibility, stigma, cultural perceptions around sexuality and sexual intercourse acts.

WEST-NILE REGION: These included; Nebbi, Arua, Moyo, Adjumani, Maracha and Terego. The MARPs characteristics range from substance use, child sex-work, fisher folk, male/female sex-work, PLHIV, long distance drivers, and uniformed services. Vulnerability was around; quick mobility, fear of consequences of visibility, stigma, cultural perceptions around sexuality and sexual intercourse acts, and inter-cultural social experiences.

NORTHERN SUB REGION: These included; Acholi and Lango Sub-region. The MARPs characteristics range from substance use, child sex-work, fisher folk, MSM, male/female sex-work, PLHIV, young people who are sexually active, long distance drivers, and uniformed services. Vulnerability was around; quick mobility, fear of consequences of visibility, stigma, cultural perceptions around sexuality and sexual intercourse acts.

IN-DEPTH INTERVIEWS:

 “As a town dweller, I do know of substance use, anal sex, female sex-work, male sex-work and child sex-work in this town and many others. The clients include professional persons, odd-jobs workers, artisans, students and non-school young people”.  Ashraf (Wandegeya), Florence (Nansana), Grace (Kawempe), Jerome (Migyeera), Cosma (Nimule) and Rashid (Mbale).

“Am a male sex-worker since 2007, my kind of clients have my phone contacts and book in different hotels in different towns of Uganda. They send me a text message and we meet for sex. Most times they also ask me to bring other friends when they are many. Some of our clients do use substances, especially they smoke marijuana”. Crystal (Kampala).

“We want to be trained in skills to start up alternative businesses besides depending on Fishing”. Bukenya (Kyamuswa, Mazinga, Kalangala Islands of Lake Victoria), Arthur (Lake Albert), Ogwer (Lake Kioga).

“Yes, there are programmes on HIV and Human Rights as part of the prison services, hopefully this will be a big step in improving prevention practices”.  (Key informant).

“Am interested in two things now that we have met. How your organisation can help us “handle” MARPs since we are increasingly working in that area” . (Key informant from a leading health organisation).

“ What is that nonsense? Every one is a MARP!” ( Key informant and district official).

“ The issues such as stigma, dialogue around discrimination and their relation to HIV are points to start with in starting and driving conversation around MARPs issues”. (Key informant and Community Development Officer).

“Am a trans-woman and I feel so insecure. I have to keep in-doors and only get out at night or make sure I put on long coats and a cap if am to conduct outreach services for other trans-women in Uganda”. (Leader of Trans-Women Bureau Uganda).

“ I am a transgendered male to female person and my parents are aware of my sexuality and gender identity. I wonder why we do not have seminars targeting parents and families. Our families are the first points of insecurity for many of the gay people.” (Leader of Young MSM Club in Uganda).

“ We are ready to conduct community campaigns against “mob-justice”  as this is one very unjust way communities deal with what they disagree with. Communities should learn to use the justice system and believe in it. Other reported complaints are evictions, black-mail, extortion and deliberate hostility actions”. (Key informant from law and order section).

LIMITATION: This exercise was conducted to generate vulnerability before testing and it explored issues around visibility of various MARPs.

CONCLUSION:  Contexts ranging from Policy, programmes, public and private settings form and influence actions targeting MARPs issues. HIV risk is one major issue most organisations target. However, before testing or accessing an HCT service MARPs need to be looked at as vulnerable and that vulnerability is disproportionate. Criminalization, Stigma and violence form a barrier that silences MSM, Sex-workers and substance users and it may cause them to go underground. This may not be the case for fisher folk, Long distance truckers or uniformed services. MARPs issues include demand for skills training to access anti-poverty programmes such as social grants. Public and private settings have all the basics in place to provide redress to all issues of MARPs. However, they are also points of violence to some MARPs.