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Exposure to work place and war time violence among female sex workers living in conflict-affected northern… Muldoon, Katherine Anne 2015

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Exposure to Work Place and War Time Violence Among Female Sex Workers Living in Conflict-Affected Northern Uganda  by  Katherine Anne Muldoon  B.Sc., McGill University, 2003 MPH, Simon Fraser University, 2010  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (School of Population and Public Health)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  October 2015  © Katherine Anne Muldoon, 2015    ii Abstract  Background and objectives: Sex workers in sub-Saharan Africa are dually affected by HIV/STIs and violence. It is estimated that over one-third of commercial sex workers in sub-Saharan Africa are living with HIV; within Uganda, the site of the current study, 37.2% of female sex workers are reportedly living with HIV compared to 8.5% among the general Ugandan female population.  There is limited information on the health and safety of sex workers living in environments affected by conflict despite the structural conditions that heighten risk of HIV infection and exposure to violence. This dissertation explores the prevalence and factors associated with exposure to violence among women currently involved in sex work in conflict-affected northern Uganda.  Methods: This dissertation drew on data from a community-based cross-sectional study of HIV prevention, treatment, and care among 400 sex workers living in northern Uganda. Analyses investigated exposure to violence from commercial sources (e.g., clients) and non-commercial sources (e.g., conflict-related violence, including abduction). Descriptive statistics were used to display the individual-level, sex work environment, and conflict related characteristics of study participants. Bivariable and multivariable logistic regression methods were used to examine demographic, conflict-related, and sex work-related factors associated with exposure to violence.  Results: 49.0% of sex workers had experienced sexual and physical violence in the previous six months, including physical assault, rape, and gang rape. Police harassment, inconsistent condom use, and managers/pimps that controlled sex workers’ negotiations were factors independently   iii associated with increased odds of violence from clients. Exposure to historical conflict-related violence was common, as 32.3% of sex workers had been abducted into the Lord’s Resistance Army. From this sample, less than half reported accessing post-abduction reintegration programming.  Conclusion: Sex workers in this study were exposed to extreme levels of commercial and non-commercial violence while concurrently facing substantial barriers to care. Rights-based policies, programming, and protective services for sex workers are needed to improve access to care and social services to reduce the burden of violence and improve health and well-being outcomes.     iv Preface  This statement certifies that the work presented in this dissertation was conceived, conducted, written, and disseminated by Katherine Muldoon (KM). All research within this dissertation received ethical approval from the University of British Columbia Behavioural Research Institutional Review Board (IRB) (Reference number: H11-00548) and The AIDS Support Organization (TASO) IRB in Uganda, and the protocol was registered at the Ugandan National Council for Science and Technology (Reference number: SS 2574) and the Republic of Uganda, Office of the President (Reference number: ADM 154/212/01). Dr. Kate Shannon (KS) is the principal investigator of the larger study and takes full responsibility for the integrity of the results and accuracy of the data. This study was funded by a CIHR global health team grant on gender, violence, and HIV (TVG-115616).  With advice from supervisors KS and Dr. Jean Shoveller (JS) and committee member Dr. Edward Mills (EM), KM designed the studies and wrote the research protocols. All chapters in this dissertation were prepared and written by KM and reviewed by KS, JS, and EM.   Co-authors of the manuscripts, including KS, JS, Monica Akello (MA1), Mirriam Ajok (MA2), Godfrey Muzaaya (GM), Annique Simo (AS), Dr. Theresa Bettancourt (TB), Zaira Petruf (ZP), Dr. Paul Nguyen (PN), and Dr. Erin Baines (EB) made contributions only as is commensurate with collegial or co-author duties.     v In the field in northern Uganda, eight Acholi research assistants (MA1, MA2, Jacky Ayat, Beatrice Baraka, Bibian Achan, Grace Lakot, Winnie Amunu, Andrew Mijumbi Ojok) were trained and supervised by KM in study protocols and data collection with support from the Ugandan and Canadian research team.  With guidance from KS, JS, and EM, KM conducted the literature review presented in Chapter 1 and 2. The statistical analyses were performed in collaboration with AS in Chapter 3. MA1, GM, AS, EM, JS, and KS provided contextual and scientific input and approved the final version of the manuscript presented in Chapter 3. The statistical analyses presented in Chapter 3 were performed in collaboration with PN. KM performed all statistical analyses included in the Chapter 4. GM, TB, MA1, MA2, ZP, PN, EB, and KS provided contextual and scientific input and approved the final version of the manuscript presented in Chapter 4.  All manuscripts contained in the thesis were prepared, written, and edited by KM. Final drafts of the manuscript were prepared following the inclusion of material based on comments from all co-authors listed above, the journal editors and external peer-reviewers. The analyses presented in Chapter 2 are currently under review. The analyses in Chapter 3 are in press. The analyses in Chapter 4 have been published.   Chapter 2 publication:  Muldoon, K.A. (under review). A systematic review of the clinical and social epidemiological research among sex workers in Uganda.    vi Chapter 3 publication: Muldoon, K.A., Akello, M., Muzaaya, G., Simo, A., Shoveller, J., Shannon, K. (in press). Policing the Epidemic: High burden of workplace violence among female sex workers in conflict-affected northern Uganda. Accepted at Global Public Health.  Chapter 4 publication: Muldoon, K.A., Muzaaya, G., Betancourt, T.S., Ajok, M., Akello, M., Petruf, Z., Nguyen, P., Baines, E.K., Shannon, K. (2014). After Abduction: Exploring access to reintegration programs and mental health status among young female abductees in northern Uganda. Conflict and Health, 8(5), 1-9.    vii Table of Contents  Abstract .......................................................................................................................................... ii!Preface ........................................................................................................................................... iv!Table of Contents ........................................................................................................................ vii!List of Tables ............................................................................................................................... xii!List of Figures ............................................................................................................................. xiii!List of Abbreviations ................................................................................................................. xiv!Acknowledgements ...................................................................................................................... xv!Dedication .................................................................................................................................. xvii!Chapter 1: Background, rationale, and objectives .....................................................................1!1.1! Health and human rights for sex workers .......................................................................... 1!1.2! Legal status of sex work .................................................................................................... 2!1.2.1! Conflation of sex trafficking and sex work ................................................................. 5!1.3! Sex work in sub-Saharan Africa ........................................................................................ 7!1.3.1! Sex work research in Uganda ..................................................................................... 8!1.3.2! Criminalization of sex work in Uganda .................................................................... 10!1.4! Exposure to commercial and non-commercial violence .................................................. 11!1.4.1! Commercial violence against sex workers ................................................................ 11!1.4.2! Non-commercial violence against sex workers ........................................................ 13!1.5! Barriers to care and safety ................................................................................................ 15!1.5.1! Barriers to consistent condom use ............................................................................ 15!1.5.2! Barriers to health care and protective services ......................................................... 15!1.6! Sex work in militarized environments ............................................................................. 16!  viii 1.6.1! Research with sex workers in conflict-affected environments ................................. 18!1.6.2! Key populations in Uganda: Sex workers and the armed forces .............................. 20!1.7! Civil war in northern Uganda .......................................................................................... 20!1.7.1! Legacy of abduction in northern Uganda .................................................................. 21!1.7.2! Disarmament, Demobilization, and Reintegration (DDR) programming ................. 22!1.8! Research aim .................................................................................................................... 24!1.9! Theoretical orientation ..................................................................................................... 25!1.9.1! Social epidemiology .................................................................................................. 27!1.9.2! Conceptual framework .............................................................................................. 29!1.10! Methods.......................................................................................................................... 31!1.10.1! Study procedures ..................................................................................................... 31!1.10.2! Research team ......................................................................................................... 32!1.10.3! Recruitment ............................................................................................................. 33!1.10.4! Clinical testing ........................................................................................................ 34!1.10.5! Data collection ........................................................................................................ 34!1.10.6! Ethical considerations ............................................................................................. 35!1.11! Organization of the dissertation ..................................................................................... 37!Chapter 2: Systematic review of sex work research in Uganda ..............................................40!2.1! Introduction ...................................................................................................................... 40!2.2! Methods............................................................................................................................ 44!2.2.1! Search strategy .......................................................................................................... 44!2.2.2! Inclusion/exclusion criteria ....................................................................................... 46!2.2.3! Data extraction and synthesis .................................................................................... 46!  ix 2.3! Results .............................................................................................................................. 46!2.3.1! Disease burden .......................................................................................................... 54!2.3.2! Condom use .............................................................................................................. 55!2.3.3! Access to care ........................................................................................................... 57!2.3.4! Violence .................................................................................................................... 58!2.4! Discussion ........................................................................................................................ 58!2.4.1! Sex work environment .............................................................................................. 59!2.4.2! Commercial and non-commercial violence against sex workers .............................. 61!2.5! Limitations ....................................................................................................................... 63!2.6! Conclusion ....................................................................................................................... 63!Chapter 3: Commercial violence against sex workers: High burden of client perpetrated violence among sex workers in conflict-affected northern Uganda ........................................65!3.1! Introduction ...................................................................................................................... 65!3.2! Methods............................................................................................................................ 68!3.2.1! Procedures ................................................................................................................. 68!3.2.2! Data collection .......................................................................................................... 68!3.2.3! Measures ................................................................................................................... 69!3.2.3.1! Dependent variable ............................................................................................ 69!3.2.3.2! Independent variables ........................................................................................ 69!3.2.3.3! Data analyses ..................................................................................................... 70!3.3! Results .............................................................................................................................. 71!3.3.1! Descriptive characteristics ........................................................................................ 71!3.3.2! Bivariable analyses ................................................................................................... 72!  x 3.3.3! Multivariable analyses .............................................................................................. 75!3.4! Discussion ........................................................................................................................ 75!3.5! Limitations ....................................................................................................................... 78!3.6! Conclusion ....................................................................................................................... 79!Chapter 4: Non-commercial violence against sex workers: LRA abduction and access to post-conflict reintegration programming among sex workers in conflict-affected northern Uganda ..........................................................................................................................................80!4.1! Introduction ...................................................................................................................... 80!4.1.1! Post-conflict programming for abductees: Disarmament, Demobilization, and Reintegration (DDR) programming ...................................................................................... 82!4.1.2! LRA abduction in northern Uganda .......................................................................... 84!4.1.3! Objectives ................................................................................................................. 85!4.2! Methods............................................................................................................................ 86!4.2.1! Sampling and recruitment strategy ........................................................................... 86!4.2.2! Measures ................................................................................................................... 87!4.2.2.1! Abduction related variables ............................................................................... 87!4.2.2.2! Mental health ..................................................................................................... 88!4.2.3! Data analyses ............................................................................................................ 89!4.3! Results .............................................................................................................................. 90!4.4! Discussion ........................................................................................................................ 93!4.5! Limitations ....................................................................................................................... 99!4.6! Conclusion ..................................................................................................................... 100!Chapter 5: Discussion, recommendations, and conclusions ..................................................101!  xi 5.1! Summary of study findings ............................................................................................ 101!5.2! Study strengths and limitations ...................................................................................... 103!5.3! Potential implications ..................................................................................................... 105!5.3.1! Support for the decriminalization of sex work ....................................................... 105!5.3.2! Sex work community peer-led outreach ................................................................. 107!5.3.3! Interventions for conflict-affected environments .................................................... 108!5.3.4! Future research ........................................................................................................ 110!5.4! Conclusions .................................................................................................................... 112!Bibliography ...............................................................................................................................113!Appendices ..................................................................................................................................136!Appendix A : Search strategy and results summary ............................................................... 136!Appendix B : Overview and characteristics of qualitative studies on sex workers in Uganda................................................................................................................................................. 141!   xii List of Tables  Table 2.1 Overview and characteristics of included studies …………………………………….49  Table 3.1. Types of violence among 196 sex workers in Gulu, northern Uganda who experienced client violence in the previous six months……………………………………………………….72  Table 3.2 Sample characteristics of sex workers in Gulu, northern Uganda who experienced client violence in the previous six months compared to those who have not (n=400)…………..73  Table 3.3. Bivariable and multivariable associations for the correlates of client violence in the previous six months among sex workers in Gulu, northern Uganda (n=400)…………………...74  Table 4.1. Characteristics of sex workers with a history of abduction (n=129) who accessed a reintegration program compared to those who did not…………………………………………..91  Table 4.2. APAI descriptive statistics and between group test of means among sex workers with a history of abduction who accessed reintegration programming compared to those who did not (n=129)…………………………………………………………………………………………...94       xiii List of Figures   Figure 1.1: Conceptual framework for investigating the social and structural determinants of experiences of violence among sex workers living in Gulu, northern Uganda.…………………………………………………………………………………………..30  Figure 2.1: PRISMA flow chart: Study selection for systematic review of sex work studies in Uganda …………………………………………………………………………………………..47  Figure 4.1: Variation in abduction frequencies over the historical timeline of the war…………92      xiv List of Abbreviations   95% CI 95% Confidence Intervals AIC Akaike Information Criterion AIDS Acquired Immunodeficiency Syndrome ART Antiretroviral Therapy DDR Disarmament, Demobilization, and Reintegration GBV Gender-Based Violence HCT HIV Counselling and Testing HIV Human Immunodeficiency Virus IDP Internally Displaced Persons ILO International Labour Organization IQR Interquartile Range LMIC Lower-Middle Income Country LRA Lord’s Resistance Army NGO Non-Governmental Organization NSWP Global Network of Sex Work Projects STI Sexually Transmitted Infection TASO The AIDS Support Organization UNAIDS Joint United Nations Programme on HIV/AIDS UNDDR United Nations Disarmament, Demobilization, and Reintegration Resource Centre UNDP United Nations Development Programme UNFPA United Nations Population Fund UNHCR United Nations High Commission for Refugees UNICEF United Nations Children’s Fund UPDF Uganda People’s Defense Force WHO World Health Organization     xv Acknowledgements  I would like to extend my sincere gratitude to my supervisory committee. I have grown tremendously as a researcher under your collective supervision. Thank you to Dr. Jean Shoveller for your kindness and skillful mentorship in the execution of this research project. I also thank Dr. Edward Mills for your enduring support, training, and technical expertise in the field of complex emergencies and global health. I would particularly like to thank my supervisor Dr. Kate Shannon. Your fearless dedication to the rights of sex workers has been a true source of motivation for my development as a researcher in the field of social justice.  I am ever grateful to my research and supervisory team in Uganda. To Drs. Josephine Birungi and Christine Nabiryo, thank you for your ongoing encouragement and strategic advice throughout my research career in Uganda. To the Gulu research team: Godfrey, Monica, Mirriam, Jacky, Bibian, Beatrice, Grace, Winnie and Andrew – I thank you for your friendship, perseverance and contributions to making this project possible. A special word of thanks to Drs. David Moore, Bill Cameron, Angela Kaida, Aranka Anema, Tara Lyons, and Kora Debeck, who have provided much appreciated mentorship over the years.  Funding for this research was generously provided by the Canadian Association for HIV/AIDS Research (CAHR), University of British Columbia, and Liu Institute for Global Issues. The International AIDS Society, CAHR, and Institute of Gender and Health within the Canadian Institute for Health Research (CIHR) generously provided financial support so that I could attend their annual conferences and present this research. This research would not have been possible without the generous technical and financial support from the Gender and Sexual Health   xvi Initiative at the BC Centre for Excellence in HIV/AIDS and The AIDS Support Organization. I also wish to extend thanks to my examining committee, Drs. Jerry Spiegel, Sunera Thobani, Matthew Chersich, and Luke Mullany, for their time and critical appraisal of this work. I would also like to acknowledge the anonymous peer-reviewers whose comments significantly improved the quality of my published work. Technical copyediting and proofreading was provided by Annique-Elise Goode of Goode Communication.  Thank you to my fellow graduate students who have been an endless source of support and laughter: Putu Duff, Ruth Lavergne, Alexis Crabtree, Chelsea Himsworth, Allison Watts, Saskia Sivananthan, Steve Kanters, Eric Druyts, Alexis Palmer, and Lindsay Galway.  I want to thank my family: Mom, my late father, Jen, John and Senga – you are my biggest source of love, support and encouragement and I am truly grateful. And to my gentle baby Nico, for all that creative and curious energy.  Finally, I want to express my most sincere thanks to the women who participated in this study. Your experiences have had a profound effect on me, and this research is dedicated to support your rights to live safely.    xvii Dedication  I would like to dedicate this work to the Gulu research team and the women in northern Uganda who participated in this study.  And to my mom, Pat Muldoon. I love you.   1 Chapter 1: Background, rationale, and objectives  1.1 Health and human rights for sex workers Throughout the world, male, female, and transgendered sex workers are a key population within HIV epidemics due to the disproportionate burden of HIV among sex workers compared to the general population (World Health Organization, 2014).  Sex workers face extreme human rights abuses including violence, arbitrary arrest, social insecurity, and inadequate access to health services (Decker et al., 2014). Within legal frameworks where sex work is considered a criminal offense, sex workers are unable to seek protection from police and endure conditions where clients of sex workers, service providers, the general community, and the media can violate their human rights with impunity. Many sex workers work in dangerous and violent environments that heighten the risk of violence from multiple perpetrators (Deering et al., 2014). The reinforcing structures of criminalization and social stigmatization of sex workers inhibit their ability to protect themselves, their families, and their sexual partners from violence and health risks including HIV/STI infection (Beyrer et al., 2014).  The empirical documentation of crimes and human rights abuses against sex workers is needed to inform evidence-based policy and practice to protect sex workers and reduce harms. This is particularly the case amongst hidden populations of sex workers, such as migrants or minors, who are difficult to access and often live and work in impoverished conditions that exacerbate the spread of disease and the proliferation of violence (Baral et al., 2014; Okal et al., 2011; Poteat et al., 2014; Steen, Jana, Reza-Paul, & Richter, 2014).     2 It is estimated that 36.9% (95% confidence intervals (CI): 36.2-37.5) of sex workers in sub-Saharan Africa are living with HIV, and within Uganda, 37.2% (95% CI: 34.2-40.2) are living with HIV compared to 8.5% among the general Ugandan female population (Baral et al., 2012). Sex workers are persecuted in several countries in sub-Saharan Africa (as are people who identify as sexual minorities) and have little access to protective services, including state justice mechanisms and access to health care such as HIV/STI prevention, diagnosis, and treatment (Global Network of Sex Work Projects, 2014a).     Sex workers with current or historical exposure to conflict or war, face compounding challenges including forced displacement and migration, extreme violence, economic instability, and lack of resources and services – all conditions that elevate risks for HIV. While there is a growing evidence base documenting the extreme burden of sexual and physical violence that sex workers face in settings and regions where they have little to no rights (Deering et al., 2014; Shannon et al., 2014) – the experiences of sex workers in conflict-affected environments are not well documented or understood (de Waal, 2010b). This is an important area for further inquiry in sub-Saharan Africa, a region highly affected by both HIV and conflict, where there remains a need for more epidemiological data on the health and safety of sex workers (Baral et al., 2012; Decker et al., 2014; Shannon et al., 2014).    1.2 Legal status of sex work The criminalization of sex work is considered one the most powerful structural determinants affecting the environments where sex workers live and work (Decker et al., 2014). Total criminalization is a framework where all aspects of sex work are criminalized including the sale   3 of sex, solicitation, communication for the purposes of sales, and third party entities such as clients, brothel owners, pimps/managers, or those otherwise living off the avails of sex work (Open Society Foundation, 2015). Where sex work is considered a criminal offence, sex workers are increasingly exposed to violence, cannot go to police for protections, and face heightened barriers to health and social services (Shannon et al., 2014). Total decriminalization removes all criminal and administrative laws and penalties related to all aspects of sex work and opens up a space where sex work could operate, as other occupations or industries, with access to the safe work and occupational health standards (Open Society Foundation, 2015). Most countries fall somewhere on the spectrum where some aspects of sex work are legal and some aspects remain criminalized.  Decriminalization of sex work has been globally endorsed as the best policy to promote health and human rights for sex workers (Sex Workers Education & Advocacy Taskforce, 2012). Sex work advocacy groups and global governing bodies, including the World Health Organization (WHO), the United Nations Population Fund (UNFPA), the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Global Network of Sex Work Projects (NSWP) have officially supported the need for decriminalized law as part of a comprehensive HIV strategy grounded in human rights. They have stated that:  “Laws that directly or indirectly criminalize or penalize sex workers, their clients and third parties, […] can undermine the effectiveness of HIV and sexual health programmes, and limit the ability of sex workers and their clients to seek and benefit from these programs.”   4 (World Health Organization, UNFPA, UNAIDS, & Global Network of Sex Work Projects, 2012) (p.16)    In addition to laws that are explicitly associated with sex work, sex workers may be harassed through administrative or municipal bylaws including loitering, public indecency, or disorderly behavior (Open Society Foundation, 2015). In some settings, police have confiscated condoms as proof of engagement in sex work (Amon, Wurth, & McLemore, 2015).  Laws that criminalize the transmission of HIV and other infectious diseases can also be applied to sex workers and their role as a key affected population with the HIV epidemic (Braun et al., 2012). Additionally, immigration laws designed to prevent sex trafficking can target sex workers and conflate adult consensual sex work with sex trafficking.  Legalization is a process whereby sex work is made legal and brought into regulatory protocols controlled by the state. It can include licensing through sex workers registries, health and safety checks with sex workers and brothels and other venues, support for 100% condom use, and regular screening for disease (Open Society Foundation, 2015). Germany and the Netherlands have legalized sex work, and sex workers living in those two contexts pay taxes and are therefore eligible for unemployment insurance and other work-related benefits (Mossman, 2007; procon.org, 2009). In some cases, the legalization of sex work can have negative consequences where sex workers who are registered with the government can have their files sent to the police causing potential barriers to gaining non-sex work related work in the future. Additionally, more marginalized sex workers, including those living with HIV or those who are underage, may not   5 go through the registration process and will operate outside of state support (Gaines et al., 2013; Laurent et al., 2003).   Even in states where sex work is legal or decriminalized, societies commonly view sex workers as amoral and often fail to view them as women, men, and transgender people deserving of human rights (Beyrer et al., 2014). Sex workers are often considered social outcasts and a threat to public health (Dhana et al., 2014; Mtetwa, Busza, Chidiya, Mungofa, & Cowan, 2013; Richter et al., 2010; Scorgie, Vasey et al., 2013). Some countries may have progressive laws designed to reduce the burden of HIV that also apply to sex workers, however the health and well-being of sex workers may not be the main reason to pursue public health action (procon.org, 2009). For example, public health policies encouraging condom use with sex workers could be designed with the primary purposes of protecting the health of clients, partners of clients, or non-commercial partners of sex workers.  1.2.1 Conflation of sex trafficking and sex work The criminalization of sex work has been argued to perpetuate the conflation of adult consensual sex work with sex trafficking. All human trafficking, including sex trafficking and sexual exploitation of children, is a grievous human rights abuse under several international conventions, including the Convention on the Rights of the Child (United Nations, 1990), the Universal Charter of Human Rights (United Nations, 1948), the Worst Forms of Child Labour Convention (International Labour Organization, 1999), and the Convention Against Transnational Organized Crime (United Nations, 2004). The United Nations has defined sex trafficking as the use of threat, force, abduction, deception or coercion for forced sexual labour   6 (United Nations, 2004). In contrast, sex work takes place between consenting adults and often sex workers are well positioned to identify trafficked individuals (Open Society Foundation, 2015).   The conflation of sex work and trafficking has contributed to policies, such as the “Anti-Prostitution Loyalty Oath” (APLO) within the United States President’s Emergency Plan for AIDS Relief (PEPFAR) (PEPFAR Watch, 2011), a policy that directly resulted in elevated risk for sex workers (Steen et al., 2014). The APLO imposes two conditions where no funds “may be used to promote or advocate for the legalization or practice of prostitution” and “no funds may be used by an organization that does not have a policy explicitly opposing prostitution” (Supreme Court of the United States, 2013). Under the auspices of PEPFAR funding, many organizations have stopped providing services for sex workers or have been blocked from seeking PEPFAR funding altogether (Ditmore & Allman, 2013). The policy also restricts the use of research funds and the ability to amass information for evidence-based policy and programming (Ditmore & Allman, 2013; Gostin, 2013a, 2013b).   Empirical research on sex trafficking in sub-Saharan Africa is limited, however forced sexual labour of women and girls has been documented in African countries with mass migration and conflict, including Uganda, Liberia, Sudan, and Sierra Leone (Amowitz, Reis, Lyons, Vann, & Taylor, 2002; Decker, Oram, Gupta, & Silverman, 2009; Karunakara et al., 2004; Simic, 2009). The failure to distinguish sex trafficking from adult consensual sex work has resulted in a narrow narrative that portrays all women living in areas affected by conflict who are exchanging sex for   7 resources as victims of trafficking. There is currently limited information on formal commercial sex work in settings affected by conflict.  1.3 Sex work in sub-Saharan Africa In most countries in sub-Saharan Africa, all aspects of sex work are criminalized. This is the case in Angola, Equatorial Guinea, Eritrea, Gabon, Ghana, Guinea, Kenya, Liberia, Mozambique, Namibia, Rwanda, Somalia, South Africa, Tanzania, and Uganda (Mgbako & Smith, 2010). Some countries have legislation where the sale of sex is legal but procurement, solicitation in public spaces, brothel ownership, and pimping are illegal. This is the case in countries such as Burkina Faso, Cape Verde, Central African Republic, Cote d’Ivoire, Ethiopia, Lesotho, Madagascar, Malawi, Sierra Leone, Swaziland, and Zimbabwe (Mgbako & Smith, 2010).   Senegal is the only country where sex work is legal, regulated by the government, and services for sex workers have existed since 1969 (Pisani & Caraël, 1999); however, soliciting, brothel ownership and pimping are prohibited by law. Legal sex workers must be 21 years of age or older, carry a record of medical health and register at an STI clinic, and their file is forwarded to the police department (Mgbako & Smith, 2010). The regulation of sex work has improved uptake of medical services, access to condoms, and treatment for HIV/STIs. Among those registered, however, research has shown that registration can further isolate more marginalized sex workers who cannot register, e.g. migrant and refugee sex workers, or sex workers living with HIV/STIs (Gaines et al., 2013; Shannon & Csete, 2010). However, despite regular access to care provided through the legal regulation of sex work, studies have documented that the estimated HIV prevalence among registered sex workers in Senegal remains high at 19.8% (Wang et al., 2007),   8 far above the national HIV prevalence of 1.0% in the general female population (Baral et al., 2012).   Even among registered sex workers, the system does not protect them from abuse from clients and police (Foley & Nguer, 2010). Some studies have shown that registered sex workers may face more police harassment than unregistered sex workers because they are known and identified through the registration process (Foley & Nguer, 2010). It is estimated that up to 80% of sex workers in Senegal are not registered and receive no formal health care (Diouf, 2007). Additionally, migrant sex workers from countries outside of Senegal cannot register. An epidemiological study found that over 75% of unregistered sex workers had at least one STI and reported lower consistent condom use compared to registered sex workers (Laurent et al., 2003), and client condom refusal is common (do Espirito Santo & Etheredge, 2003).   1.3.1 Sex work research in Uganda There is a growing body of qualitative and quantitative literature on the experiences of sex workers in Uganda. The first cohort of female sex workers – the Good Health for Women Project – was established in Kampala in 2008, in collaboration with the Medical Research Council and the Ugandan National AIDS Programme, and with extensive consultation from several local sex work and women’s NGOs (Vandepitte et al., 2011). This study used ethnographic mapping to identify sex work venues (e.g., bars, beer breweries, lodges, and guesthouses) and peer/sex worker-led outreach to invite sex workers to participate in the study and access HIV/STI testing and treatment. This multidisciplinary investigation used social, clinical, and molecular epidemiological methods among a cohort of 1027 sex workers in Kampala (Ssemwanga,   9 Ndembi, Lyagoba, Bukenya et al., 2012). At baseline, the HIV prevalence among sex workers was established at 37.0% (95% C1: 34.0-40.0) and the factors most strongly associated with sero-positivity were older age, being widowed, low educational attainment, sex work as sole income, street-based sex work, and using alcohol on dates (Vandepitte et al., 2011). Additional analyses investigating condom use suggest that early sexual debut (AOR: 1.46, 95% CI:1.09-1.96) and current alcohol use were independently associated with inconsistent condom use with clients (Bukenya et al., 2013). These analyses have begun to highlight key demographic and sex work specific variables that affect sex workers’ risk of HIV/STI infection in Uganda.  Qualitative studies conducted among a sub-sample of sex workers from this same cohort were designed to explore contextual challenges that heighten HIV risk, including exposure to violence (Mbonye et al., 2012; Mbonye, Rutakumwa, Weiss, & Seeley, 2014). These studies highlighted the contextual challenges that shape condom use and sex workers’ ability to reduce HIV risk. To avoid police presence, sex workers were commonly displaced to isolated areas, had less time to perform a safety scan on clients, and often experienced physical and sexual violence from both clients and police. Sex workers reported that soliciting at indoor establishments, such as bars or hotels, offered some protection from clients and police. Information regarding workplace factors that shape HIV risk is an important area for further inquiry.  Domestic surveillance has estimated that the HIV prevalence among sex workers living in Kampala, Uganda, was 33.0%, and 44.0% among older sex workers (>25 years) (Makerere University, Centers for Disease Control and Prevention, & Uganda Ministry of Health, 2009). The Ugandan National Surveillance Programs maintained by the Ugandan Government and   10 Ministry of Health have no data in their bi-annual Global AIDS Response Progress Report on key indicators for sex workers, including the percentage of sex workers who report male condom use with their most recent client or the percentage who have received HIV counseling and testing in the last 12 months (Uganda AIDS Commission, 2012). The lack of routinely collected statistics on the health of sex workers, including HIV risk and access to testing and treatment, continue to undermine efforts to improve the health and safety of sex workers and inhibits the ability to monitor trends. Additionally, the existing statistics are concentrated among sex workers in the urban capital of Kampala, and sex workers from more rural and isolated areas remain under-represented in the domestic surveillance statistics.   1.3.2 Criminalization of sex work in Uganda Sex work is considered a criminal offense in Uganda and sex workers regularly face police harassment, discrimination from the public, and human rights violations including arbitrary arrest, degrading treatment, and violence. The Government of Uganda has a history of persecuting sex workers, particularly their right to assembly. In 2011, the Minister of Ethics and Integrity blocked a sex workers regional workshop in Kampala and threatened to close down the hotel hosting the event (Kiapi, 2012). The Minister released a statement condemning sex work and declared that sex workers should stop citing human rights violations as a justification for their ‘crimes.’ The political persecution and social shaming of sex workers has fostered a belief that the country should not ‘waste’ antiretroviral therapy (ART) on sex workers, a group most in need of treatment (Kiapi, 2012).     11 There are several qualitative studies that have documented the dangerous effects of the criminalization of sex work in Uganda. Sex workers have reported being both physically and sexually abused by police, including extreme situations where sex workers reported being gang raped by multiple police officers (Mbonye et al., 2013; Scorgie et al., 2013). Studies reported that police would demand bribes from sex workers and those who could not pay were detained, and at times physically or sexually abused in jail (Mbonye et al., 2012). A study among male, female and transgendered sex workers with refugee status in Uganda reported being particularly fearful of police because of their insecurity associated with statelessness and refugee status (Nyanzi, 2013). These studies have been an important source of information on the experiences of sex workers living in the criminalized context in Uganda. While the dangerous consequences of the criminalization of sex work have been documented and acknowledged globally as key drivers of HIV infection, epidemiological data on the prevalence and kinds of violence among sex workers in Uganda are required.   1.4 Exposure to commercial and non-commercial violence 1.4.1 Commercial violence against sex workers A systematic review conducted by Deering et al. 2014 reviewed the epidemiological evidence from sex workers in 20 different countries, estimating that the lifetime prevalence of violence was between 45-75%, and recent violence within the past 12 months ranged from 32-55% (Deering et al., 2014). Several structural features of the sex work environment were shown to independently increase the risk of violence including practices associated with policing (e.g., arbitrary arrest, extortion, bribery, raids, and displacement), physical places of service and   12 solicitation (e.g., safer indoor spaces versus outdoors), and larger economic constraints including poverty, debt, and housing instability.   Violence against sex workers is a commonly reported workplace hazard and a key risk factor contributing to elevated HIV risk (Karim, Karim, Soldan, & Zondi, 1995; Okal et al., 2011). Negotiations surrounding payment and condom use are commonly documented triggers for violence from clients (Lim et al., 2015). Sex workers reported that clients often use violence as a form of intimidation to undermine sex workers’ ability to negotiate safer sex (Scorgie et al., 2011).   Within sub-Saharan Africa, there is ongoing documentation of the high burden of physical and sexual violence against sex workers. Studies among sex workers in Togo and Burkina Faso found that 18.0% had reported violence from regular clients, 34.5% from new clients and 12.1% from police in the previous year (Wirtz et al., 2015). Another study among sex workers in Burkina Faso found that over 40% of sex workers were forced to have sex by a client, a factor that was higher among those selling sex as a minor (Grosso et al., 2015). Studies among sex workers in Benin found a high burden of violence within the previous month where 17.2%, 13.5%, and 33.5% of sex workers had experienced physical, sexual, and psychological violence, respectively (Tounkara et al., 2014). A study among 112 sex workers in Nigeria found that 72.3% had experienced client violence, and 77.7% had experienced police harassment (Popoola, 2013).     13 In Kenya, sex workers reported that 17.0% had been assaulted and 35.0% were raped by clients in the last month (Elmore-Meegan, Conroy & Agala, 2004). Alcohol use has been shown to be a factor that increases the risk of violence from clients. Studies among sex workers in Kenya reported that clients who used alcohol were more likely to be violent, and sex workers who had been drinking alcohol reported reduced ability to negotiate condom use (Chersich et al., 2007; Chersich, Bosire, King’ola, Temmerman, & Luchters, 2014; Mbonye et al., 2014). Studies of Ugandan sex workers found that clients may be less likely to pay for sex if they have already bought drinks for a sex worker (Mbonye et al., 2014). In South Africa, 64.0% of sex workers reported that at least one of their past 10 clients had been violent (Wechsberg, Luseno, & Lam, 2005).  Within Uganda, there have been several qualitative studies documenting the extreme burden of violence that sex workers face from clients, police, pimps, and other community members. Studies describe how sex workers work in dangerous environments where it is increasingly difficult to negotiate condom use with clients (Gysels, Pool, & Nnalusiba, 2002; Mbonye et al., 2012, 2014; Ntozi et al., 2003; Nyanzi, 2013; Scorgie, Nakato, et al., 2013; Scorgie, Vasey, et al., 2013; Zalwango, Eriksson, Seeley, Vandepitte, & Grosskurth, 2010). To date there remains a need for more quantitative and epidemiological evidence on violence against sex workers in Uganda.   1.4.2 Non-commercial violence against sex workers  In addition to workplace violence from clients, police, and the general public, violence from non-commercial sources continues to play an important role in the health and safety of sex workers.   14 Studies have shown that the occurrence of intimate partner violence among sex workers is common (Benoit et al., 2013; Decker, Pearson, Illangasekare, Clark, & Sherman, 2013; Jackson et al., 2009; Ngugi, Benoit, Hallgrimsdottir, Jansson, & Roth, 2012b; Panchanadeswaran et al., 2008; Wirtz et al., 2015). Intimate partner violence among sex workers has been shown to be associated with a history of childhood abuse, inconsistent condom use (Argento et al., 2014; Luchters et al., 2013), and low sexual relationship power (Muldoon, Deering, Feng, Shoveller, & Shannon, 2014), and studies have documented that consistent condom use is much lower with non-commercial partners than with commercial partners (Decker, Pearson, et al., 2013).    Studies from multiple settings have shown the high frequency of childhood trauma and exposure to historical violence among sex workers (Collins et al., 2013; Goldenberg et al., 2013; McClure, Chandler, & Bissell, 2014). Settings with increased risk of abuse among children include those affected by extreme poverty, including conflict or disaster. War-related violence against children includes family separation, starvation, neglect, sexual and physical abuse, and in extreme cases, abduction or child soldiering (Akello, Reis, & Richters, 2010; Betancourt, Borisova, et al., 2012; Lokuge et al., 2013; McMullen, O’Callaghan, Richards, Eakin, & Rafferty, 2011; Ochen, 2015; Patel et al., 2013; Saile, Ertl, Neuner, & Catani, 2014). Exposure to childhood trauma can leave a lifelong effect on physical and mental health, and the risk of re-exposure to violence as adults. Understanding more about the historical exposure to non-commercial forms of violence among sex workers remains an important area for further investigation.     15 1.5 Barriers to care and safety 1.5.1 Barriers to consistent condom use Condom availability and consistent use with clients are core components of sex worker health and safety. Access to condoms is improved through free or subsidized condom distribution and community-based programming designed to reach sex workers and provide support and education to reduce harms (Shannon et al., 2014). However, criminalization and negative policing practices (e.g., confiscating condoms as proof of engaging in sex work; fear of arrest or harassment by police) have negatively influenced condom use practices (Decker et al., 2014) and reduced sex workers’ ability and time to negotiate safer sex work practices (Lang, Salazar, DiClemente, & Markosyan, 2013; Mooney et al., 2013; Shannon et al., 2014; Urada, Morisky, Hernandez, & Strathdee, 2013; Wang et al., 2009).   To avoid encounters or harassment from police, sex workers may work alone or move to more isolated and dangerous areas to solicit for clients where they have less control over transactions and less time to do a safety scan of the client (Shannon et al., 2014). This has been shown to reduce male condom use and increase the likelihood of experiencing violence from clients (Deering et al., 2014; Karim et al., 1995). Additional socio-demographic factors that contribute to non-condom use include low literacy and education among sex workers and their clients and the use of alcohol/drugs (Scorgie, Vasey, et al., 2013).   1.5.2 Barriers to health care and protective services Discrimination against sex workers is a commonly documented barrier to health care and protective services (Aung, Paw, Aye, & McFarland, 2014; Global Network of Sex Work   16 Projects, 2014a; Pitpitan, Kalichman, Eaton, Strathdee, & Patterson, 2013).  Sex workers often fear that their confidentiality will be violated by health care workers (e.g., their HIV/STI status may be disclosed). Research in North America has documented a high prevalence of discrimination from health providers associated with reduced access to health care services (Lazarus et al., 2011). Some sex workers may not disclose their occupation to health care providers for fear of patronization and discrimination or out of the belief that they are undeserving of treatment (Parker & Aggleton, 2003). Congregating around programming and services that are welcoming for sex workers may also increase sex workers’ risk for arrest via police crackdowns (Decker et al., 2014).  Qualitative studies from sex workers in Kenya, Zimbabwe, Uganda, and South Africa describe a high burden of unmet health needs, citing the denial of services from health providers as a key barrier to care (Scorgie, Nakato, et al., 2013). Other barriers to health care include prohibitive fees, inflexible schedules, and the lack of safe spaces that are sex work friendly (Mtetwa et al., 2013). Establishing safe spaces for sex workers to access care is considered best practice and a necessary component of rights-based care for sex workers.    1.6 Sex work in militarized environments Military personnel are key populations targeted for HIV/AIDS prevention, particularly when soldiers are deployed (Lloyd, Papworth, Grant, Beyrer, & Baral, 2014; Whiteside, de Waal, Gebre-Tensae, & Whiteside, 2006). A systematic review across 11 countries documented the pooled HIV prevalence in male military populations to be 1.08% (95% CI: 0.58%-1.59%), and   17 military populations in sub-Saharan Africa had significantly higher odds of HIV infection (OR: 2.8, 95% CI:1.01-7.81) compared to adult men in the general population (Lloyd et al., 2014).   Military personnel on peacekeeping missions may have more disposable income and have the financial means to purchase sex. In militarized environments, there are often high rates of partner turnover (including transactions with sex workers), while condom availability and use may be low (Hallum-Montes et al., 2012; Larsen et al., 2004; Whiteside et al., 2006). This has been documented in countries affected by violent conflict with a prominent military presence, including Uganda, the Democratic Republic of Congo (DRC), Sierra Leone, Afghanistan, Sri Lanka, and Haiti (Internal Displacement Monitoring Centre, 2011a).  Many countries have begun to document and monitor interactions between sex workers and military personnel as two key groups for HIV prevention (Anastario, Tavarez, & Chun, 2010; Whiteside et al., 2006). In DRC, military stationed in the capital of Kinshasa had an HIV prevalence of 3.8% and syphilis infection prevalence of 11.9%, partially attributed to inconsistent male condom use in the previous 12 months with sex workers and other casual partners (Rimoin et al., 2015). Among the Angolan military, 9.0% reported having sex with a sex worker in the previous 12 months, and only 54.2% reported using a condom during the last transaction (Bing et al., 2010). In Guinea Bissau, 28.9% reported contact with a commercial sex worker since joining the army, a factor that was associated with increased odds of HIV infection (OR: 2.90, 95% CI: 1.75-4.73) (Biague et al., 2010).    18 Studies among military based in Belize and the Dominican Republic reported that up to 31.0% of soldiers had sex with a sex worker in the last 12 months, and over 80.0% had a lifetime history of sex with a sex worker (Hallum-Montes et al., 2012). A study among police and military personnel in Peru, found that few men (1.3%) had sex with sex workers, however, those who did reported high consistent condom use with sex workers (75.5%) (Villaran et al., 2009). From a sample of Afghan National Army recruits, 21.3% reported paying for sex with a female or male sex worker (Todd et al., 2012).   This body of literature has been an important source of information on HIV risk in areas affected by conflict; however, the research was conducted among military personnel, documenting their interactions with sex workers. There is far less research where sex workers are the primary research participants. As a result, there is limited information about the contextual challenges associated with safer sex work in environments affected by conflict.  1.6.1 Research with sex workers in conflict-affected environments In general, sex workers are considered a hard-to-reach population, who are often mobile and face legal and cultural conditions that create barriers to accessing services and participating in research. These challenges are magnified within volatile environments affected by conflict where it is also challenging to conduct research. Studies among sex workers living in Afghanistan, a country that has faced chronic conflict since the 1980s, documented that from a sample of 520 sex workers, fewer than 60% had heard of condoms and of those who had, only half had ever used a male condom (Todd et al., 2010). The levels of HIV knowledge and consistent condom   19 use among this population was low, and the risk of HIV infection and violence was higher among sex workers living in rural areas (Todd et al., 2011).   In DRC, a country faced with civil and regional wars since the 1990s, a study of 136 sex workers in Kinshasa reported the common pattern of charging more for unprotected sex with clients. This practice was associated with living in non-urban areas and having at least one child, which were conceptualized by the authors as proxies for the dual challenge of low socioeconomic status with financial responsibility for dependents (Ntumbanzondo, Dubrow, Niccolai, Mwandagalirwa, & Merson, 2006). Structural and social pressure from clients and financial incentives for consenting to unprotected sex have been cited as barriers to condom use among female sex workers in a number of settings where structural support to ensure condom use is limited (Shannon et al., 2014). In Burma, where the HIV epidemic is one of the most severe in Asia, a cross-sectional survey of 978 female sex workers from seven different cities estimated that between 28-73% of sex workers have tested for HIV in the last year (Aung et al., 2014). Although the sample size was small (n=69), studies among sex workers in Tripoli, Libya found a HIV prevalence of 15.7%, 38.6% had undergone HIV testing in the last 12 months, and 5.8% had been arrested in the previous 12 months (Valadez et al., 2013). Among a sample of 201 commercial sex workers in Sierra Leone, only 38.0% reported using a condom at last sex and less than 60% had reported using a condom ever (Larsen et al., 2004). A study among 129 sex workers in northern Uganda found that 41.1% were living with HIV (Muldoon, Muzaaya, et al., 2014). There is a recognized need for improved services and access for sex workers in conflict-affected areas but limited evidence to inform programming and policy.    20 1.6.2 Key populations in Uganda: Sex workers and the armed forces In Uganda, both the armed forces and sex workers are considered two key, and inter-related, populations for HIV programming as listed in the Global AIDS Response Progress Report (Uganda AIDS Commission, 2012). The heightened risk of HIV among mobile forces and sex workers has historical significance in Uganda. In 1986, soldiers from the Ugandan People’s Defense Force (UPDF) were deployed to Cuba for military training, where 30.0% of the army tested positive for HIV through routine screening offered through the Cuban government (Tumushabe, 2006). It has been hypothesized that the identified high prevalence of HIV within the UPDF prompted the state-sponsored campaign acknowledging HIV as a national issue and population health concern. While many countries in sub-Saharan Africa had delayed acknowledgment and action to prevent the spread of HIV, Uganda was one of the first countries in the region to take an active role in addressing the spread of the HIV epidemic through testing, condom promotion, and access to antiretroviral treatment (Tumushabe, 2006). However, Uganda also took a very aggressive stance on sex work and the criminalization of sex workers has limited access to services, increased HIV risk through reduced condom use with clients, and is currently threatening the success of HIV programming.   1.7 Civil war in northern Uganda One of the longest wars in sub-Saharan Africa took place in northern Uganda. The conflict between the Lord’s Resistance Army (LRA) and the Government’s Ugandan Peoples Defense Forces (UPDF) lasted over two decades, during which it is estimated over 1.8 million people were moved into approximately 250 internally displaced persons (IDP) camps managed by the Government of Uganda (UNHCR, 2011). IDP and refugee camps are designed to provide   21 displaced populations with shelter and basic requirements and are intended to be a short-term solution; however, globally, it is estimated that the average length of stay in a camp is 17 years and is likely much longer in northern Uganda where the war lasted over 20 years (Internal Displacement Monitoring Centre, 2011b; UNHCR, 2013).   IDP camp inhabitants in northern Uganda lived in constant insecurity, witnessing and experiencing extreme acts of violence from both the LRA and the UPDF. The LRA was accused of mutilating civilians, planting landmines, and burning and looting villages. Thousands of people died during the war, many families were torn apart (Rujumba & Kwiringira, 2010), and household-based surveys conducted in the camps showed a high number of unaccompanied minors – children most likely to be killed, sexually and physically abused, abducted or recruited as child soldiers (UNICEF, 2014b). By 2005, it was estimated that more than 50% of the camp populations were under 15 years of age and many children and adolescents were living in the absence of family care and protections (Boas & Hatloy, 2006). Inter-inhabitant violence was also rampant in the IDP camps. Studies conducted in 2010 documented that 51.7% of women who lived in the northern Ugandan IDP camps reported intimate partner violence in the past year, and 41.0% experienced forced sex by their husbands (Stark et al., 2010).  1.7.1 Legacy of abduction in northern Uganda It is estimated that between 25,000 and 66,000 youth between the ages of 13 and 30 were abducted into the LRA over the course of the war (Blattman, 2006). The majority of abductees were young boys and men conscripted to fight as soldiers, and it is estimated that between 25.0-40.0% were young women who served as porters and ‘wives’ (Berkley-Tulane Initiative on   22 Vulnerable Populations, 2007; Dolan, 2009; Vindevogel, Ager, Schiltz, Broekaert, & Derluyn, 2015; Vindevogel, Wessells, De Schryver, Broekaert, & Derluyn, 2012). To reduce the chances of being abducted, children would walk into larger urban areas, sleep overnight in the towns, and return to the camp during the day. This phenomenon was known as night-commuting, and it is estimated that thousands of children commuted to town to sleep in churches, sleeping centres or on the streets each night (Westerhaus, Finnegan, Zabulon, & Mukherjee, 2008).  The UNICEF-sponsored Survey of War Affected Youth (SWAY) reported that 78.0% of abducted youth witnessed a killing and 63.0% were physically assaulted during abduction (Blattman, 2006). Gender-based analyses documented that women and girls were reported to have spent significantly longer lengths of time in captivity compared to boys and men, likely because they were abducted to serve as porters and sexual partners of soldiers, compared to abducted boys and men who were most commonly conscripted to serve as soldiers with higher mortality rates (Blattman & Annan, 2006).   1.7.2 Disarmament, Demobilization, and Reintegration (DDR) programming In response to the high number of abductions during the Ugandan civil war, the United Nations Disarmament, Demobilization, and Reintegration (DDR) programming was applied to support the transition into the post-conflict phase of the war. Disarmament (i.e., physical removal of weapons and munitions) and demobilization (i.e., disbanding of armed groups) occur relatively early in peace processes (UNDDR, 2012). Reintegration is a much longer process whereby former combatants and abductees acquire civilian status and support services to reintegrate into post-conflict society (Inter-Agency Working Group on DDR, 2006). It is a complex and open-  23 ended process between the combatants, abductees, and the recipient community. The objectives of reintegration programs are generally to provide support and opportunities to live ‘normal’ lives, become a functional member of society, resume education, gain skills training, and reduce the effects of trauma, anxiety, and depression (UNDDR, 2012).   Fewer women and girls go through the official UN processes of DDR and continue to face substantial challenges in their physical and psycho-social recovery, including experiences of trauma, depression, anxiety, and social ostracization (Betancourt, Borisova, de la Soudiere, & Williamson, 2011; Mckay, 2004). Access to reintegration support in northern Uganda has been documented in many reports (Inter-Agency Working Group on DDR, 2006; United Nations Department of Peacekeeping Operations, 2010) and has been evaluated in some peer-reviewed studies (Mckay, 2004; Patel et al., 2013). Several studies have documented low uptake and access to reintegration programming (Muldoon, Muzaaya, et al., 2014; Ochen, 2015; Pham, Vinck, & Stover, 2009; Pham, Vinck, & Weinstein, 2010). However, access to these services among female LRA abductees remains an understudied topic and important area for investigation.   Sexual risk faced by women affected by war is an important area for further investigation, particularly sexual risks associated with sex work. Sex work advocacy groups in Uganda have stated that women and girls who grew up in IDP camps commonly look for income in the sex trade and are in need of protection from violence as well as improved access to care (Kiapi, 2012).    24 1.8 Research aim The goal of this dissertation was to document experiences of violence, HIV, and access to care among female sex workers living in conflict-affected northern Uganda. The analyses herein take place within a population of female sex workers sampled from Gulu, northern Uganda, who work in a political environment where sex work is criminalized and live in a social environment recovering from violent conflict. The analyses investigate commercial violence against sex workers (e.g., violence from clients) and non-commercial conflict-specific experiences of violence (e.g., LRA abduction).  The specific objectives were to:  1. Identify and synthesize the results of the quantitative epidemiological literature on sex workers in Uganda, with a particular focus on research that described the prevalence of HIV/STIs, access to care, and exposure to violence among sex workers in Uganda.    2. Document the forms of violence perpetrated by clients against sex workers and examine the specific relationship between policing and client violence, in addition to a broad range of structural-level and individual-level factors;   3. Describe the proportion of sex workers with a history of LRA abduction, explore abduction-related experiences including access to post-abduction reintegration programming, and mental health.     25 1.9 Theoretical orientation Social and structural determinants are processes whereby political laws, social norms or a combination of both, create divisions among social groups, channeling resources and power to privilege some groups and disenfranchise others (Galtung, 1969). The global movement to investigate the social determinants of health is important for a number of reasons: 1) it represents a conceptual shift towards the conditions producing social disparities between populations and how and why they shape individual agency. This is in contrast to focusing on individuals and individual-level change without incorporating social and structural conditions that constrain choice and behavior; 2) this area of research can lead to positive structural changes at the political and societal level. As Galtung (1969) originally argued:  Resources are unevenly distributed, as when income distributions are heavily skewed, literacy/education unevenly distributed, medical services existent in some districts and for some groups only…The situation is aggravated further if the persons low on income are also low in education, low on health, and low on power – as is frequently the case because these rank dimensions tend to be heavily correlated due to the way they are tied together in the social structure. (p. 171)   Achieving individual-level improvements in health outcomes is intractably connected with multiple macro-level structural forces that restrain agency and reproduce poverty and powerlessness. Those who are marginalized by society can face considerable barriers to a safe and healthy life, and their barriers are less likely to be documented (Farmer, 2007). Reducing or eliminating the effects of social marginalization on individual health and mitigating the resultant   26 inequities associated with various forms of marginalization is a complex task. Indeed, inequities are rarely the result of a single, modifiable factor. Intersectionality, however, offers a means by which to examine interactions amongst multiple dimensions (e.g., race/ethnicity, gender, class, education, sexuality, geography, age, and religion) so as to more completely understand how combinations of factors affect health and social inequities (Bowleg, 2012; Hankivsky, 2012). Intersectionality also provides an approach to foreground the ways in which individual experiences are shaped by relationships and power dynamics situated at more macro-, system levels. This includes the effects of laws and policies, gender norms, war, migration, and the legacy of colonialism and imperialism (Anderson, 2010; Peterson, 2007; Thobani, 2005).     Many people who experience oppression may come to internalize the conditions that they live in and perceive them as legitimate and natural – concept known as symbolic violence (Bourdieu & Wacquant, 2007). For example, in many settings, male dominance is considered a ‘natural’ component of social life despite the damaging consequences of gender inequities (e.g., gender-based violence, socioeconomic gender disparities) (Bourdieu, 2007). Social norms of male dominance have been shown to entrench violence and worsen its effects. Action to change social structures that disproportionately expose specific populations to violence and disease (e.g., social norms, male dominance, criminalization of sex work) is needed.  Importantly, the social structures that disproportionately expose certain populations to violence and disease are socially constructed and are neither permanent nor unalterable. There is no justifiable necessity to have socially constructed laws and norms in place that pose a threat to specific populations. Research that is designed to document the consequences associated with   27 discriminatory laws (e.g., criminalization of sex work) and harmful social norms (e.g., male dominance, social stigmatization of sex work) is needed if change is to occur. Evidence that can document the harms associated with specific laws and norms is also positioned to showcase the opportunities for structural and population-level change.   1.9.1 Social epidemiology Social epidemiology is a sub-discipline of population and public health, combining the analytic methods of traditional epidemiology with theoretical components of social theory. The investigation of the social determinants of health, disease, and well-being–in contrast to solely concentrating on biomedical science–are explicitly evaluated during the social epidemiological analyses of risk, exposures, and outcomes (Krieger, 2001).   The conceptual shift to investigating the social and structural determinants of health required the development of new methodologies and has supported the advancement of social epidemiology. Social epidemiology investigates patterns and conditions designated as social factors, including economic position, family and community structures, class, culture, and legal and political systems. It also analyzes the interconnected relationship between individual and collective health (Oakes & Kaufman, 2006). As summarized by Oakes & Kaufman (2006):  …social epidemiology is about how a society’s innumerable social arrangements, past and present, yield differential exposures and thus differences in health outcomes among the persons who comprise the population… it is about social allocation mechanisms (that is, economic and social forces) that produce   28 differential exposures that often yield health disparities, whether deemed good or bad (p. 3-4).  Two key frameworks that inform the discipline of social epidemiology include the rights-based framework and the social justice framework. A rights-based framework is informed by the Universal Declaration of Human Rights (UDHR) and includes such rights as the right to freedom, right to education, freedom of movement, among others (United Nations, 1948). It has the benefit of being globally endorsed, precise and practical. However, as the UDHR was draft in and by the West, it is critiqued for reproducing colonial power dynamics that may not fully represent or involve the most marginalized groups it seeks to protect. The social justice framework is a complimentary approach that looks beyond individual rights and focuses on transforming power structures that shape the inequitable distribution of resources that produce disparities and human rights abuses (Saiz & Yamin, 2013). It prioritizes links with social justice movements and grassroots groups to ensure that all approaches are localized and culturally relevant. Both approaches are not mutually exclusive or synonymous, however careful application of both is needed to transform power dynamics to promote justice and human rights.  Key areas of investigation within social epidemiological inquiry include discrimination, social aspects of disease distribution, poverty, social and biological deprivation, and exclusion (Krieger, 2001). Examining the larger structural and social determinants that shape population health is essential in order to move beyond the binary investigation of “exposure” and “disease” and explore the conditions that render entire populations and social groups marginalized. Social epidemiology seeks to measure collective-level exposure to harms and the population-level   29 burden of disease (Keyes & Galea, 2014). It is inherently difficult to quantitatively measure truly large-scale or macro forces that shape population health, and this has contributed to the scarcity of social epidemiological evidence (Galea & Link, 2013). The transitions between collective-structural level and individual-level features are challenging constructs to capture through quantitative measurement, particularly temporal issues related to historical events (Kin et al 1994).   Documenting the social and structural factors that shape people’s lives (e.g., policies, laws, geography, historical events) is essential in order to advocate for structural-level change that has the potential for large-scale shifts in population health (Galea, Riddle, & Kaplan, 2010). Despite methodological challenges, investigating how social and structural determinants contribute to disparities in health outcomes is an area of focus for social epidemiology.   1.9.2 Conceptual framework The conceptual model presented in Figure 1.1 draws from the discipline of social epidemiology and the social and structural determinants of health to investigate social-structural level experiences and how they manifest at the individual-level among women who have been affected by the civil war in northern Uganda and currently engage in sex work.        30 Figure 1.1: Conceptual framework for investigating the social and structural determinants of experiences of violence among sex workers living in Gulu, northern Uganda    Criminalized sex work environments, as outlined in section 1.2, have been shown to increase risks related to violence and morbidity including HIV/STIs, and to increase barriers to care for women involved in sex work. Under criminalized law, sex workers are unable to seek protection from police or the justice system, lack efficacy to report crimes committed against them, and face substantial barriers to care.   Conflict-affected environments are fragile states that are either currently exposed to active war or are recovering and transitioning to a state of relative peace. The war in northern Uganda   31 displaced thousands of people from their land into IDP camps, restricting freedom of movement and access to basic needs including food, water, and human security. The IDP camps were disbanded at the time of this research; however, they remain a social-structural level factor that shape the lives of all people living in northern Uganda.   Analyzing the nexus of these two social-structural level features– the criminalized sex work environment and conflict-affected environment –the analyses in this dissertation investigate commercial violence against sex workers, specifically the experience of violence from clients (Chapter 3), and non-commercial violence against sex workers, specifically historical trauma related to the war in northern Uganda, including the extreme experience of being abducted into the LRA (Chapter 4).    1.10 Methods 1.10.1 Study procedures Data for the analyses included in this dissertation come from a community-based cross-sectional study of HIV prevention, treatment, and care among 400 sex workers living in northern Uganda (May 2011-January 2012). Study eligibility criteria included: being 14 years of age or older and having exchanged sex for money or other commodities (e.g., food, childcare, school fees, shelter cell, phone air time) with a commercial client in the previous 30 days (Muldoon, Akello, Muzaaya, Simo, & Shannon, 2012; Muldoon, Muzaaya, et al., 2014). This project was conducted in partnership with The AIDS Support Organization (TASO) and the TASO clinic branch in Gulu, with consultation from other community-based women, sex work, and health service organizations. TASO is the largest indigenous HIV service organization in Uganda and, at the   32 time of this research, it had no formal programming or funding for programming with sex workers.   1.10.2 Research team The research team included: (1) six female research assistants and one male data manager who were all from the Acholi tribe and spoke Luo; (2) liaison staff at TASO-Gulu (e.g., nurses, counsellors, data managers, doctors, and guards) who provided clinical support and helped to create a safer space for sex workers to access care and treatment at TASO; and (3) six peer/sex worker outreach team members. The research assistants and TASO staff completed a 40-hour site activation training program designed by the Canadian study coordinator Katherine Muldoon (candidate), the Gulu study coordinator Monica Akello, and TASO study lead investigators Dr. Josephine Birungi, Mrs. Francis Babirye, Mr. Godfrey Muzaaya, and Dr. Esther Achan to build a foundational understanding of social justice, human rights, including women’s rights and those of sex workers and other sexual minorities. The site activation training included review of the standard operating procedures including: participant consent and enrolment, questionnaire administration, protocols for HIV counselling and testing, managing participant withdrawal, and data management. All study members completed the online training for Good Clinical Practice (Collaborative Institutional Training Initiative, 2014) and the National Institute of Health Protecting Human Subject Research Participants (National Institute of Health, 2014). Drs Shannon and Birungi were the Canadian and Ugandan principal investigators (PI) of this study.   Within TASO, the research project also consulted with the TASO-Gulu Advisory Board, Research Committee, and the Clients Council (TASO clients living with HIV who advise on   33 TASO activities). Externally, the project consulted with several administrative bodies, including the: (1) Chief Administrative Officers, a municipal branch of the Gulu region that is responsible for the management of government affairs; (2) Local Council, a multi-level form of locally elected government with representatives in each village and a coordinating Chairman in the district capital; (3) District Health Officer, a municipal representative of the Ministry of Health; (4) Chief of Police and Probation Officer; and (5) Resident District Commissioner, a district representative of the central government. Communication with these administrative bodies was essential to establish an alliance and ensure that sex workers were safe accessing the services and that the study staff were protected when they interacted with sex workers.    1.10.3 Recruitment Recruitment into this study occurred through multiple strategies. TASO identified any women who had disclosed their sex work status and referred them to the study if interested. TASO outreach was also conducted at four former IDP camps (i.e., Pabbo, Bobi, Awach, and Labongogali). Secondly, sex worker/peer-led outreach was conducted in several suburbs of Gulu where sex workers congregate, including Kasubi, Bardege, Kanyagoga, Cerelena, Konypaci, Kasubi, Layibi, Olayoilong, Laliya, and Kanyagoga. Night-time peer/ sex worker-led outreach was conducted in bars and hotels in the area, known to be key sex work spaces. Approximately two-thirds of participants were recruited through TASO programming and one-third were recruited through peer-outreach. There were no significant differences in age, education, ethnicity or abduction status by recruitment site or method. All interviews were conducted during the day either at the TASO study office or a safe space that the participants identified.     34 1.10.4 Clinical testing TASO uses the Ugandan Ministry of Health HIV testing algorithm (Uganda Ministry of Health, 2003). Each participant was offered an HIV test (Alere Determine HIV-1/2); if the results were negative, the participant was considered HIV negative. If the participant tested positive, a second confirmatory test (STAT PAK) was administered. If the first and second test results were concordant, the participant was diagnosed with HIV. If the test results were discordant, the participant was given a third confirmatory test (Unigold). The results of the third test were considered final. All study participants received condoms and risk reduction counseling, and if they tested positive for HIV, immediately received care and treatment at TASO or were referred to another service centre of their choice.   Those who tested positive for HIV were able to become TASO clients and receive care and treatment for HIV and STIs. Participants who tested negative for HIV (i.e., were unable to access care at TASO) and who reported symptoms consistent with STIs were referred to local clinical centres including Marie Stopes and Lacor Hospital. All participants were referred to the Gulu Regional Referral Hospital for Papanicolaou (Pap) tests.  1.10.5 Data collection Study questionnaires were first developed in English and then adapted by the Gulu study team and translated into the Luo language. The Luo versions were piloted with a group of Acholi sex workers that provided feedback on the appropriateness of the questions and added new questions they found important to the northern Ugandan context. Study questionnaires collected information on demographics, sex work histories and current working environments, intimate   35 partnerships, trauma and violence (including war related violence and abduction), sexual and reproductive health, and HIV prevention, treatment and care.   1.10.6 Ethical considerations This study received ethical approval from the University of British Columbia Behavioural Research Ethics Board (H11-00548) and TASO’s IRB, and the protocol was registered at the Ugandan National Council for Science and Technology (UNCST).  The study was explained verbally in the Luo language and each participant received a copy of the consent form. Participants provided written informed consent or a thumbprint in the case of limited literacy and were compensated 10,000 Ugandan Shillings (approximately 4CAD) for their time and expertise.   The legal age of consent in Uganda is 18 years and typically if a research participant is under 18 years of age, consent from a legal guardian is required. However, adapted consenting procedures have been developed to reach vulnerable populations considered to be living in the absence of guardianship. Participants between the ages of 14-17 years underwent an adapted consenting procedure where each section of the consent form was carefully explained and the youth was asked to describe back what they understood. This process allowed for further assessment of the youth participants’ ability to provide informed consent. If the youth participant was assessed as being able to provide informed consent, they were invited to take part in the study.    36 Both the benefits and risks were carefully explained to each participant. The risks associated with the study questionnaire involved asking participants to recollect potentially painful experiences. This included questions related to sex work, violence, and other topics regarding health and well-being. Participants were encouraged to return to the study office at any time if they required more support or services. Participants could skip any questions they did not want to answer and participation could be withdrawn without consequence. To mediate potential risks, the research assistants were trained in counseling and how to support a participant who may start to have an emotional response including crying or anger. Additionally, a senior TASO counselor was always available to provide additional support.   The study also included voluntary (opt-in) HIV/AIDS counseling and testing. Risks associated with HIV/AIDS counseling and testing included the physical discomfort associated with giving blood samples and the emotionally distressing effects associated with a positive HIV test. All participants went through TASO’s standard protocols for pre- and post-test counseling. All HIV tests were conducted in a private environment where the conversations between the counselor and participant could not be overheard. Any newly infected participants could immediately seek treatment and care at TASO or another care facility of their choice.   Main benefits associated with participation in the study included knowing their HIV status and receiving risk-reduction counselling. The study also offered the opportunity to access health and supportive services. Referrals were provided for services that fell outside the scope of clinical services provided by TASO. Involvement in research also provided an opportunity to share experiences for the purposes of improving the health and safety of sex workers.     37  Beyond the standard guidelines for the ethical conduct of research, there are specific ethical considerations needed for research conducted as part of partnerships involving researchers from the global North and South. As described in Section 1.10.2, considerable time and effort was taken to ensure that the study had meaningful involvement for multiple stakeholders. Reflexive research practice also demands acknowledgement of the fact that I am a white, middle-class Canadian woman with over 10 years of post-secondary education, conducting research among women living in northern Uganda who were currently involved in sex work. Additionally I do not speak Luo (the language of the Acholi tribe predominantly affected by the war). My reflexive approach was influenced by my previous experience working with TASO (since 2008) and many of the staff knew me. Taken alongside the powerful and complex social residue of colonialism and persistent inequitable North-South power relations, it was imperative throughout my research process to continually be reflexive and sensitive to these dynamics.   1.11 Organization of the dissertation This dissertation consists of five chapters. Chapter 1 provides an introduction and literature synthesis of the current evidence base pertaining to violence, HIV/STIs, and access to care among female sex workers, particularly those who live and work in post-conflict settings, such as northern Uganda. Chapter 1 also includes a description of the methodology used in this study.   Chapter 2 is a systematic review of the epidemiological research on sex workers in Uganda. This review summarizes the findings from 20 quantitative studies conducted primarily in the urban capital of Kampala and along the trans-Africa highway. The prevalence of HIV infection   38 ranged from 32.4-52.0%. Between 33.3-55.1% of sex workers reported inconsistent condom use in the previous 30 days. Key gaps in the literature included limited information on commercial and non-commercial experiences of violence among sex workers.   Chapter 3 documents exposure to commercial sex work related violence and describes the most common forms of client-perpetrated violence among sex workers in the Gulu district of northern Uganda. This analysis investigates the specific association between policing and client violence in addition to a full range of demographic and work environment factors that influence client violence. These results document a violent working environment, where 49.0% of sex workers had experienced extreme sexual and physical violence in the last six months, including rape, gang rape, and physical assault. The social-structural level factors that increased the odds of client violence included rushing negotiations because of police presence, servicing clients in bars, inconsistent condom use with clients, and having a pimp or manager.   Chapter 4 is a descriptive analysis documenting historical war-related experiences of violence among sex workers living in northern Uganda. The study reports that 32.3% of sex workers had been abducted into the LRA between 1988-2010 at the median age of 13 years. The majority of the sample escaped from captivity (76.6%) or was released by the LRA (15.6%). After departure, less than half (43.4%) of the abductees had accessed supportive reintegration programming, the most common form being a traditional cleansing ceremony, amnesty or going to a reception centre. Abductees who accessed reintegration programming were compared to those who did not, and between group differences in current mental health status were assessed. Significant between group differences in mental health were not observed between those who   39 accessed programmatic reintegration and those who did not. The findings also suggest that many female abductees were not able to access reintegration services, and that longer-term services may be needed to detect differences in mental health.   Chapter 5 provides a discussion of the findings from the dissertation, areas for future study, and the limitations and strengths of the research presented herein.       40 Chapter 2: Systematic review of sex work research in Uganda  2.1 Introduction The high prevalence of HIV among sex workers has been consistently documented from the beginning of the HIV epidemic (Papworth et al., 2013). Studies from the early 1980s began to document the high prevalence of HIV among sex workers within Uganda (Berkley et al., 1989; Fleming, 1988; Hennis et al., 1988). The Ugandan Government has been a leader in acknowledging the scale of the HIV epidemic within the general population and began large scale campaigns to encourage condom use and reduce the number of sexual partners from the beginning of the epidemic (Marcus, 1993). As a result, there is a large body of clinical research on HIV in Uganda, including many clinical trials, particularly concerning sero-discordant couples (Baeten et al., 2012) and the prevention of mother to child transmission (Siegfried, Van Der Merwe, Brocklehurst, & Sint, 2011), but much less among sex workers (Van Damme et al., 2008). Despite the early recognition of the need for specialized programming to reduce the spread of HIV among sex workers, sex workers have continued to carry a disproportionate burden of HIV. Country-wide prevalence estimates, based on available data, suggest that approximately one-third or 37.2% (95% CI: 34.2-40.2) of female sex workers are living with HIV in Uganda compared to 8.5% among the general Ugandan female population (Baral et al., 2012). The sustained levels of HIV suggest that there are larger structural barriers to health care and social and environmental factors that constrain sex workers’ choices and ability to reduce risk and exposure to HIV (Beyrer et al., 2014; Kerrigan et al., 2013; Ngugi, Roth, Mastin, Nderitu, & Yasmin, 2012).     41 In response to the high burden of disease among sex workers and their position as a population heavily affected by the HIV epidemic, there has been a growing body of literature investigating the prevalence and risk factors associated with HIV risk among sex workers. In addition to the high burden of HIV/STIs among sex workers across sub-Saharan Africa (Baral et al., 2012; Djomand, Quaye, & Sullivan, 2014; Ngugi, Roth, et al., 2012; Papworth et al., 2013; Shannon et al., 2014), there has also been a focus on the factors that influence sex workers’ ability to protect themselves, their clients, intimate partners, and families from risk (Beyrer et al., 2014). Sex workers often have limited economic options and provide for many dependent children and family members, with limited access to education (Deering et al., 2014; Ngugi, Benoit, Hallgrimsdottir, Jansson, & Roth, 2012a; Ngugi, Roth, et al., 2012; Scorgie et al., 2011).  In many countries in sub-Saharan Africa, sex work is criminalized and sex workers are often persecuted with little protection available from police or social services. This is the case in Uganda. In 2014, the government of Uganda passed the Anti-Pornography Act (Parliament of Uganda, 2011), also known as the “Miniskirt Bill.” Under the Anti-Pornography Act, pornography is considered a criminal offence and is defined as “a) a person engaged in explicit sexual activities or conduct; b) exposing sexual parts of a person such as breasts, thigh, buttocks or genitalia; c) erotic behavior intended to cause sexual excitement; or d) any indecent act or behavior tending to corrupt morals.” The Anti-Pornography Act does not specifically use the terms prostitution or sex work; however, the broad scope of the Act provides sufficient legal infrastructure to arrest, detain, and harass sex workers upon sight.    42 Despite the development of the Anti-Pornography Act, the Ugandan government has made a commitment to improve access to HIV care and treatment for sex workers and recognized the disproportionate burden of HIV that they face in the Ugandan National HIV Strategic Plan (Government of Uganda, 2013). Qualitative research among sex workers in Uganda has shown that the criminalized status of sex work excuses extreme violence against sex workers, inhibits their ability to reduce HIV risk and negotiate condom use, and often displaces them to isolated and dangerous areas to avoid police harassment (Mbonye et al., 2012, 2013, 2014; Scorgie, Nakato, et al., 2013). Despite the ongoing documentation of the increased HIV risk, to date there has been no acknowledgement from the Ugandan government that criminalizing sex work could undermine HIV prevention efforts.  Many studies have documented the extreme human rights abuses that sex workers face including homicide, physical and sexual violence, unlawful arrest or detention, and discrimination when accessing health services (Decker et al., 2014; Deering et al., 2014; Shannon et al., 2014). Sex workers will often forgo condom use because of fear of violence from clients, police or pimps/managers (Beyrer et al., 2014; Chersich et al., 2013; Deering et al., 2014; Scorgie et al., 2011). Although there is limited epidemiological research, there is a growing body of qualitative research among Ugandan sex workers describing the common occurrence of violence from clients, including extreme acts of gang rape and physical assault (Mbonye et al., 2012, 2013; Ntozi et al., 2003; Schoemaker & Twikirize, 2012; Scorgie, Vasey, et al., 2013). Studies have documented that police can be both perpetrators and enablers of violence against sex workers. To date, there is limited quantitative evidence on the burden of violence against sex workers in Uganda, an important and neglected area for investigation.    43  Reviews of the literature among sex workers in sub-Saharan Africa have documented a high unmet need for comprehensive health care services that include HIV treatment, prevention and care, sexual reproductive health, harm reduction, and psychosocial support (Beyrer et al., 2014; Moore et al., 2014; Scheibe, Drame, & Shannon, 2012). Ensuring equitable and non-judgmental access to HIV care for sex workers in sub-Saharan Africa is a priority identified by sex work advocacy and community groups (Baleta, 2014; Scorgie, Nakato, et al., 2013) and endorsed by global governing bodies (UNAIDS, 2012; World Health Organization et al., 2012; World Health Organization, 2014). Even with examples of successful service provision, many remain small in scope and precariously funded, and few are able to address the structural drivers of risk including discrimination, violence, and lack of protections through criminalized law (Dhana et al., 2014). Qualitative studies among sex workers in Uganda have cited discrimination from health care providers and difficulty accessing condoms as key barriers to care (Schoemaker & Twikirize, 2012; Scorgie, Nakato, et al., 2013). Engaging sex workers in the continuum of HIV care is a necessary component of HIV prevention and treatment. Consequently, many sex workers may not know their HIV status, lack access to testing and treatment, and face stigma and discrimination from health care providers that inhibit retention in care (Chersich et al., 2013; Dhana et al., 2014). Specialized programming and effective interventions to increase condom use, access to HIV/STI testing and treatment, and access to primary and comprehensive care for sex workers are needed (Shahmanesh, Patel, Mabey, & Cowan, 2008).   In response to the recognition of heightened risk of HIV/STI infection and transmission among sex workers, several studies have been conducted in Uganda – the context of the current   44 dissertation research. To contextualize and summarize existing research evidence pertaining to sex work in Uganda, particularly the prevalence of HIV/STIs and factors that influence risk, I undertook a systematic review and synthesis of the quantitative literature on sex workers in Uganda published in English.  2.2 Methods 2.2.1 Search strategy Prospero, the prospective registration platform for systematic reviews was searched on March 8, 2015 to determine if there was an existing systematic review registered or published on topics related to sex workers in Uganda (National Institute for Health Research, 2015). None was found. A more sensitive search strategy was designed to retrieve studies from other electronic bibliographic databases. Database selection and search strategy development followed the Cochrane Collaboration’s current international MECIR standards for conducting systematic review searches. I identified items from the following databases on March 10-11, 2015:   Cochrane Library via Wiley (Issue 3 of 12, 2015); Campbell Collaboration Library of Reviews; MEDLINE and PreMEDLINE via OVID (1946-present); PSYCINFO via OVID (1861 – present); Sociological Abstracts via Proquest (1952-present); Dissertations and Theses via Proquest (1743-present); EconLit  via Proquest (1982-present); IDEAS Economics and Finance Research via web (all years); British Library for Development Studies (BLDS) via web (all years); ISI-Web of Knowledge via Thompson; Web of Science Core Collection: Citation Indexes; Science Citation Index Expanded (SCI-EXPANDED) (1900-present); Social Sciences Citation Index (SSCI) --1900-present; Arts & Humanities Citation Index (A&HCI) --1975-present; Conference Proceedings Citation Index- Science (CPCI-S) --1990-present; Conference   45 Proceedings Citation Index- Social Science & Humanities (CPCI-SSH) --1990-present; Health Evidence (database of public health systematic reviews) (all years); CAB Direct (CAB Abstracts & Global Health) (all years).  Searches were conducted for all years, in all languages. For maximum sensitivity, no study design filters were applied. Given the multidisciplinary nature of this topic, databases from the fields of medicine, health, social science, and economics, and sources of grey literature (i.e., IDEAS, BLDS) were selected. The search strategy was devised for the OVID Medline interface, tested using relevant, target articles, and then adapted for the other databases. The reference lists of papers selected for full text appraisal were scanned for additional potentially relevant material.  All references were imported into an EndNote Library and tagged with the name of the database. Duplicates were removed manually within EndNote, leaving a final total of 351 results (333 from the electronic databases and 18 from other sources). The reporting of the search and selection results adhered to PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) (Moher, Liberati, Tetzlaff, & Altman, 2009). Complete search strategies for all sources are available in Appendix A.  The literature review was designed to identify any studies on sex work in Uganda. Sex work terms included: “sex work” or  “sex workers” or prostitut* or brothel* or escort or “sex adj3 buy*” or “commercial adj3 sex*” or “sex adj3 industry.” Search terms to restrict articles to Uganda included: Uganda or Kampala or Kira or Mbarara or Mukono or Gulu or Nansana or   46 Masaka or Kasese or Hoima or Lira or Mbale or Masindi or Njeru or Jinja or Entebbe or Arua or Wakiso or Busia or Iganga or Mpondwe or Kabale or Soroti or Mityana or Mubende.  2.2.2 Inclusion/exclusion criteria All studies that included sex workers as the primary research participants were included in the review. Sex work was defined as exchanging sex for money or other resources as a commercial activity. Sex workers could be self-identified as female, male or transgendered. The review was not restricted to any specific content area; however, only studies with quantitative methodology were included in the final review.  Studies that focused solely on transactional sex were excluded from the review. Transactional sex was defined as non-commercial or informal exchange of sex for resources.  Studies where third-party participants reported on interactions with sex workers (e.g., military, truck drivers, community members, health service providers, etc.) were not included. This search was then restricted to research studies conducted in the country of Uganda.   2.2.3 Data extraction and synthesis The following data was extracted from the studies: source, setting, objective, design, sample size and characteristics, results including prevalence rates, and risk factors for various outcomes.  2.3 Results Figure 2.1 provides the outlay for the study selection process. A total of 484 articles were retrieved from the database search; 18 were identified through the grey literature and hand   47 searching. After removal of duplicates, a total of 351 articles were screened for eligibility and 62 full-text articles were assessed.   Figure 2.1. PRISMA flow chart: Study selection for systematic review of sex work studies in Uganda  The final review included 20 studies with quantitative methodology conducted among sex workers in Uganda (Table 2.1). The included studies were published between 1997 and 2015.   48 There were 17 quantitative studies and three mixed method studies from six original data sources. There were five studies from multi-national research collaborations. Three studies were conducted as part of a randomized controlled trial (RCT) investigating the clinical effectiveness of a vaginal microbicide gel to prevent HIV infection,1 with study sites in Uganda, South Africa, Benin, and India (Guédou et al., 2012, 2013; Van Damme et al., 2008). This trial was halted prematurely because there were higher rates of HIV acquisition among sex workers assigned to the intervention arm.   Two studies were conducted among sex workers working along the Mombassa-Kampala corridor (Morris & Ferguson, 2006; Morris, Morris, & Ferguson, 2009). The study collected information from 1007 bars at 47 truck stops, 8 truck stop sites were in Uganda, and 39 in Kenya.   A total of 15 studies were conducted solely within Uganda: 12 studies included sex workers from Kampala (Matovu & Ssebadduka, 2012; Redd et al., 2014; Schwitters et al., 2015; Ssemwanga, Ndembi, Lyagoba, Bukenya, et al., 2012; Ssemwanga, Ndembi, Lyagoba, Magambo, et al., 2012; Van Damme et al., 2008; Vandepitte, Muller, et al., 2012; Vandepitte, Weiss, et al., 2014; Vandepitte et al., 2011, 2013; Vandepitte, Bukenya, et al., 2012; Vandepitte, Hughes, et al., 2014). Three studies were conducted among sex workers in trading towns near Lake Victoria in south-western Uganda (Pickering, Okongo, Bwanika, Nnalusiba, & Whitworth, 1997; Pickering, Okongo, Nnalusiba, Bwanika, & Whitworth, 1997; Pickering, Okongo, Ojwiya, Yirrell, & Whitworth, 1997). All studies were among female sex workers; there were no studies with male or transgendered sex workers.                                                 1 CONRAD Sulfate randomized control trial http://www.isrctn.com/ISRCTN95638385   49 Table 2.1. Overview and characteristics of included studies Source  Setting Design Objective Sample size and characteristics Results Bukenya et al, 2013 Kampala Longitudinal Cohort: cross-sectional baseline analysis To describe the prevalence and determinants of inconsistent condom use N=905 sexually active sex workers 40% inconsistent condom use with paying clients in the last month. Increased risk: sex work not the sole source of income, sexual debut before 14 years, daily consumption of alcohol, fewer paying clients in last month, and currently pregnant. Decreased risk: currently married, higher number of sexual partners   Guédou et al, 2012 Multisite: Uganda (Kampala), South Africa, Benin, India  Double blind RCT: cross-sectional secondary analysis To examine the association between prevalent vaginal flora abnormalities, BV and HIV infection among all sex workers screened for the RCT  N=1367 sex workers, n=516 Ugandan sex workers Among total sample, 27.0% HIV prevalence, 47.6% BV prevalence, and 19.2% IVF. BV and IVF were significantly associated with HIV.  Sub-analyses: Among Ugandan sex workers, HIV prevalence 32.4%, additional stratified analyses not available.  Guédou et al, 2013 Multisite: Uganda (Kampala), South Africa, Benin, India  Double blind RCT: longitudinal secondary analysis To examine predictors of recurrent bacterial vaginosis N=440 sex workers with >1 episode of BV, n=167 from Uganda Among total sample, BV incident rate of 20.8 recurrences/100-person-months; Risk factors: vaginal cleansing increased risk; consistent condom use and vaginal candidiasis decreased risk  Sub-analyses: Among Ugandan sex workers, 7.9 recurrences/100 person-months. No additional stratified analyses available.    50 Source  Setting Design Objective Sample size and characteristics Results Matovu et al, 2012 Kampala Cross-sectional survey To assess sexual risk behaviours, condom use and STI infection among sex workers  N=259 Ugandan sex workers  55.08% used condoms inconsistently in past month; 77.22% self-reported STI in past 12 months; 86% sought treatment 3 days after recognition of symptoms; Consistent condom use was 72.1% with causal partners, 40.8% with regular partners, 6.3% with spouses  Morris et al, 2006 Multisite - Uganda/Kenya on the Mobassa-Kampala highway  Longitudinal study: diaries of sexual activity for 30 days To exploring the effect of condom use among sex worker on the trans-Africa highway in contributing to HIV epidemic  N=578 Ugandan/Kenyan sex workers, n=175 Ugandan  Total of 14072 sex acts, 77.7% of sex acts used condoms; Modelling – using HIV prevalence of 30-50% it was estimated there are 3200-4148 new HIV infections per year on the Mombasa-Kampala highway  Morris et al, 2009 Multisite - Uganda/Kenya on the Mobassa-Kampala highway  Longitudinal study: diaries of sexual activity for 30 days  To describe sexual behaviour among sex workers on the Mombasa-Kampala highway, compare risk between Ugandan and Kenyan sex workers  N=578 Ugandan/Kenyan sex workers, n=175 Ugandan  Compared to Ugandan sex workers, Kenyan sex workers had higher consistent condom use (79% vs 74%), more likely to use condom during sex act, higher condom use with regular clients,    Compared to Ugandan bars, bars in Kenya were more likely to: have condom dispensers, (25% vs 1%); distribute or sell condoms, (73.9% vs 47.6%); and have more weekly condom distribution.  Pickering et al, 1997a Fishing village in south-western Uganda Longitudinal study: diaries of sexual activity for 6 months To describe sexual mixing patterns inside and outside town N=26 sex workers Women contributed 421 women-weeks; 15 were married and 42% of sex partner were with commercial partner; 11 were single and 20% of sex acts were with non-commercial partners; 90% of contacts were from men resident in the village.    51 Source  Setting Design Objective Sample size and characteristics Results Pickering et al, 1997b Trading town in south-western Uganda Longitudinal study: diaries of sexual activity for 6 months To describe sexual mixing patterns  N=48 sex workers Women contributed 789 women-weeks; average 5.8 clients per week; 10% of clients were non-commercial; condom use was 99% with commercial partners  Pickering et al, 1997c Trading town and fishing village in south-western Uganda Longitudinal study: diaries of sexual activity for 6 months To describe sexual mixing patterns N=81 sex workers Women contributed 1280 women-weeks; 34 women from fishing villages and rural areas 90% of sex acts with local men; 47 women from town contacts 87% of sex partners were with with truck drivers or outside clients; 52% were HIV positive, no significant difference by location  Redd et al, 2014 Kampala Longitudinal Cohort: longitudinal clinical analysis To determine the rates of HIV primary and super-infection among sex workers in Kampala  N=85 HIV positive sex workers  The prevalence of HIV superinfection was 8.2% (3.4/100 person-years) and was not significantly different from the rate of primary infection in the same population (3.7/100 person-years)  Schwitters et al, 2015 Kampala Cross-sectional survey To estimate the prevalence of client initiated violence in the previous 6 months among sex workers N=1467 sex workers 81.8% had experienced at least one form of client-initiated violence in previous 6 months: 39.1% physical abuse, 45% verbal abuse, 50% forced sex, 56% not paid.   Increased risk of violence: longer duration in sex work, more frequent client demand for unprotected sex, consumption of 5+ alcoholic drink, soliciting in outdoor spaces (e.g. streets, parks, parking lots etc)    52 Source  Setting Design Objective Sample size and characteristics Results Ssemwanga et al, 2012a Kampala Longitudinal Cohort: longitudinal clinical analysis To identify prevalence of multiple HIV infections and associated features of partnership histories  N=324 HIV-positive sex workers 9% had multiple infections, sex workers working in same localities had phylogenetically similar viruses Ssemwanga et al, 2012b Kampala Longitudinal Cohort: longitudinal clinical analysis To classify HIV drug resistance among ART naïve women with new HIV diagnosis  N=42 ART naïve sex workers with new HIV diagnosis HIV drug resistance point prevalence estimate of 2.6% (95% confidence interval, 0.07%-13.8%)   Van Damme et al, 2008 Multisite: Uganda (Kampala), South Africa, Benin, India  Double blind RCT: primary analysis To investigate efficacy of cellulose sulphate microbicide gel to reduce new HIV infection  N=1398 HIV-negative sex workers total; N=303 Uganda sex workers  Cellulose sulphate gel did not prevent HIV infection and may have increased the risk of HIV acquisition, hazard ratio 1.61 (0.86-3.01).  Within Ugandan sub-group, sex workers reported 17-19 (med) sex partners, 19-21 (med) sex acts in previous 7 days. 97.5% condom use per sex act. Additional stratified analyses not available  Vandepitte et al, 2011 Kampala Longitudinal Cohort: cross-sectional baseline analysis To examine baseline prevalence and risk factors of HIV and STIs N=1027 Ugandan sex workers HIV prevalence 37%, gonorrhoea 13%, trachomatis 9%, T. Vaginalis 17%, BV: 56%, candida infection 11%, HSV-2 antibodies 80%, active syphilis 10%.  Increased HIV risk: older age, widowed, lack of education, sex work as sole income, street-based sex work, not knowing HIV status, using alcohol and intravaginal cleansing with soap.     53 Source  Setting Design Objective Sample size and characteristics Results Vandepitte et al, 2012a Kampala Longitudinal Cohort: cross-sectional baseline analysis To assess the prevalence and determinants of mycoplasma genitalium (MG) among sex workers  N=1025 endocervical swabs from sex workers MG prevalence: 14% - more prevalent in HIV+; less prevalent in older women, those who were pregnant but never gave birth. Associated with gonorrhoeae, candida, trichomonas vaginalis  Vandepitte et al, 2012b Kampala Longitudinal Cohort: cross-sectional baseline clinical analysis To describe the symptoms and signs associated with MG among Ugandan sex workers  N=1027 Ugandan sex workers MG prevalence 14%, increased risk: dysuria and mucopurulent vaginal discharge,  Vandepitte et al, 2013 Kampala Longitudinal Cohort: longitudinal clinical analysis To investigating the patterns of clearance and recurrence of untreated MG  N=119 sex workers with MG Overall clearance rate 25.7/100 person years; 55% spontaneiously cleared infection within 3 months, 83% within 6 months, 93% within 12 months. Infection recurred in 39% of women.  Vandepitte et al, 2014a Kampala Longitudinal cohort: nested case control To examining the temporal association between MG status prior to HIV infection   N=168, n=42 cases, n=126 controls  42 sex workers acquired HIV during the study, incident rate of 3.66/100 person years; Non-significant association between MG infection and HIV acquisition   Vandepitte et al, 2014b Kampala Longitudinal Cohort: longitudinal clinical analysis To assess the prevalence and antimicrobial susceptibility patterns of gonorrhoea among sex workers in Kampala  N=148 sex workers with diagnosis of gonorrhoea  83.1% ciproflaxin resistance, 68.2% penicillin resistance. 97.3% tetracycline resistance    54 In the review process, 13 studies with qualitative methodology were identified. As this dissertation is epidemiological, the systematic review followed PRISMA guidelines and excluded qualitative studies and non-original research. However, given the thesis is based on social epidemiology, the qualitative research gives critical context and voice to sex workers’ narratives and lived experiences. The 13 qualitative studies were reviewed and summarized separately in Appendix B, and key narratives related to the research are summarized within the discussion of this review.   2.3.1 Disease burden Three studies reported the HIV prevalence among Ugandan sex workers, representing 1411 sex workers across two regions of Uganda – two studies in Kampala and one study in south-western Uganda. The HIV prevalence among female sex workers across the three studies ranged from 32.4% to 52.0% (Guédou et al., 2012; Pickering, Okongo, Ojwiya, et al., 1997; Vandepitte et al., 2011). Independent factors shown to significantly increase the risk of HIV infection included older age (>25 years), being widowed, having less than primary education, sex work as sole income, street-based sex work, not knowing HIV status, using alcohol, and intravaginal cleansing with soap.  Eleven studies reported on the prevalence of STIs. The prevalence of bacterial vaginosis (BV) was between 47.6-55.0%, (Guédou et al., 2012, 2013; Vandepitte, Bukenya, et al., 2012). The prevalence of herpes simplex virus-2 (HSV-2) was 79.9%, gonorrhoea was 13.0%, trichomonas vaginalis was 17.1%, candida infection was 10.9%, active syphilis was 10.0%, and chlamydia was 8.9% (Vandepitte et al., 2011). Between 8.2-9.0% of sex workers had multiple HIV   55 infections (Redd et al., 2014; Ssemwanga, Ndembi, Lyagoba, Bukenya, et al., 2012), with evidence suggesting that sex workers working in close proximity to each other had genetically similar viruses. Multidrug resistance to antiretroviral therapy was observed in 2.6% of sex workers with HIV (Ssemwanga, Ndembi, Lyagoba, Magambo, et al., 2012) and among a sub-sample of 148 sex workers with gonorrhoea, 83.1% were resistant to ciproflaxin, 68.2% were resistant to penicillin, and 97.3% were resistant to tetracycline (Vandepitte, Hughes, et al., 2014). The prevalence of Mycoplasma genitalium (MG) infection was 14.0%, and higher in HIV-positive women than in HIV-negative women (Vandepitte, Bukenya, et al., 2012; Vandepitte, Muller, et al., 2012). MG clearance was shown to be slower among sex workers living with HIV and those with lower CD4 cell counts (Vandepitte et al., 2013). MG infection was also shown to increase the risk of HIV acquisition (Vandepitte, Weiss, et al., 2014). Among a sample of 259 sex workers in Kampala, 76.5% of sex workers self-reported an STI in the past 12 months (Matovu & Ssebadduka, 2012).  2.3.2 Condom use Eight studies reported on patterns of condom use among sex workers with recall periods ranging from the previous week to the previous six months. Inconsistent condom use within the previous month ranged from 33.3-55.1%.   In analyses of Kenyan and Ugandan sex workers along the Mombasa-Kampala corridor, it was estimated that condoms were used in 77.7% of sex acts in the previous month (Morris & Ferguson, 2006). Compared to Ugandan sex workers, Kenyan sex workers reported higher   56 condom use per sex act (79.2% vs. 73.9%) and higher frequency of 100% condom use (26.8% vs. 18.9%) (Morris et al., 2009).   Analyses within a large cohort of sex workers from Kampala (Good Health for Women Project) found that 40.2% of sex workers reported inconsistent condom use in the previous month. Factors significantly associated with inconsistent condom use included sex work not being the sole source of income (AOR = 1.54; 95% CI: 1.13-2.09), sexual debut before 14 years (AOR = 1.46; 95% CI: 1.09-1.96), daily consumption of alcohol (AOR = 1.90; 95% CI: 1.26-2.88), and being currently pregnant (AOR = 2.11; 95% CI: 1.25-3.57). Being currently married (AOR = 0.36; 95% CI: 0.18-0.73) and having a higher number of sexual partners per month were both associated with a lower risk of inconsistent condom use (Bukenya et al., 2013). In sub-analysis of sex workers with paying clients in the previous month, only 33.9% reporting consistent condom use (Vandepitte et al., 2011).   Within the microbicide randomized control trial, Ugandan sex workers reported 97.5% consistent condom use with clients in the last week (Van Damme et al., 2008). A study among sex workers in Kampala found that 94.0% of sex workers had reported using a condom at least once in the previous month; however, 55.1% used condoms inconsistently. Condom use varied by partner type and was highest with casual partners (72.1%), regular partners (40.8%), and spouses (6.3%) (Matovu & Ssebadduka, 2012).  Studies among sex workers in a trading and fishing town in south-western Uganda reported between 94.0-99.0% used condoms with commercial partners and 59% of non-commercial   57 partners in the previous six months (Pickering, Okongo, Nnalusiba, et al., 1997; Pickering, Okongo, Ojwiya, et al., 1997). The authors cautioned that these findings were likely subject to social desirability bias.    One study included condom use as a independent variable in the regression modeling but did not include prevalence estimates, however client condom refusal significantly increased the odds of physical, verbal, sexual violence, and economic deprivation in the previous 6 months (Schwitters et al., 2015).  2.3.3 Access to care Six studies reported on access to health care and services. Three studies reported on access to sexual health care, including access to condoms and STI testing and treatment. One study reported that 37.7% of sex workers had never tested for HIV (Vandepitte et al., 2011). Among sex workers in Kampala, 76.5% of sex workers self-reported an STI in the past 12 months and of those, 93.0% sought treatment and 78.2% completed the treatment (Matovu & Ssebadduka, 2012). An analysis of the sex work environment along the Mombasa-Kampala corridor found that compared to bars in Uganda, bars in Kenya were more likely to have condom dispensers (25.0% vs. 1.0%), distribute or sell condoms, (73.9% vs. 47.6%), and have more weekly condom distribution (Morris et al., 2009).  Although no quantitative estimates were reported, three studies conducted in the fishing and trading towns in south-western Uganda cite that there was no health clinic or health services in   58 the villages at the time of the research (Pickering, Okongo, Bwanika, et al., 1997; Pickering, Okongo, Nnalusiba, et al., 1997; Pickering, Okongo, Ojwiya, et al., 1997).  2.3.4 Violence One study reported on commercial forms of violence against sex workers (Schwitters et al., 2015). In the previous 6 months, 81.8% of sex workers had experienced at least one form of client-initiated violence, 39.1% had experienced physical abuse, 44.7% verbal abuse, 49.1% forced sex acts, and 54.9% had not been paid after sex. Rape from any partner in the last 6 months was 41.3%. No studies reported on violence from police or the general public.   One study reported on non-commercial forms of violence against sex workers (Schwitters et al., 2015). The lifetime prevalence of rape was 49.0% with the most common perpetrator from the last rape being an intimate partner (18.2%), friend (8.2%), authority figure (3.4%), and family member (2.1%). No studies reported on historical or childhood violence.  2.4 Discussion The aim of this systematic review was to summarize the epidemiological research pertaining to sex workers living and working in Uganda. There were a total of 20 studies using quantitative methodology that were conducted over the past 18 years, reporting a high prevalence of HIV and other STIs among sex workers.  The largest source of information about sex workers in Uganda is from a cohort of over 1000 sex workers in Kampala (Vandepitte et al., 2011). It documented a high prevalence of HIV (37.0%),   59 and the presence of other STIs including gonorrhoaea, syphilis, and bacterial vaginosis. Both antiretroviral drug resistance and antibiotic drug resistance were identified within this cohort. The study also identified a high prevalence of inconsistent condom use in the previous month (40.2%). Early sexual debut and daily consumption of alcohol were statistically significantly associated with inconsistent condom use. This study collected information from 2008-2009, and is source information for several Government of Uganda national HIV reports (Government of Uganda, 2010, 2013).   2.4.1 Sex work environment The epidemiological research about sex workers in Uganda is largely concentrated in Kampala. Twelve of the 15 studies conducted solely in Uganda included female sex workers from Kampala. Many investigations of sex workers in sub-Saharan Africa take place in urban centres and there are likely very large populations of sex workers working in Kampala. However, extending beyond urban capitals is an important area for future research with sex workers.  Five studies were conducted along the trans-Africa highway. Three studies were conducted in trading and fishing towns in south-western Uganda, which described complex sexual mixing patterns between commercial and non-commercial partners (Pickering, Okongo, Bwanika, et al., 1997; Pickering, Okongo, Nnalusiba, et al., 1997; Pickering, Okongo, Ojwiya, et al., 1997). There was high reported condom use among commercial partners and low condom use with regular and non-commercial partners. Two qualitative studies among this population were identified, which also reported that consistent condom use was more difficult with regular partners (Gysels, Pool, & Bwanika, 2001; Gysels et al., 2002). Fishing communities surrounding   60 Lake Victoria have high HIV prevalence rates and are considered a key population within the national HIV strategic plan in Uganda (Government of Uganda, 2013). The role of sex work within fishing communities is an important area for ongoing investigation (Smolak, 2013).  HIV research along trucking routes has been an important source of information regarding mobile populations and spread of HIV (Beyrer et al., 2011; Coates, Richter, & Caceres, 2008; Delany-Moretlwe et al., 2014; Magnani, Sabin, Saidel, & Heckathorn, 2005; Richter, Scorgie, Chersich, & Luchters, 2014). This review identified two studies conducted along the Mombasa-Kampala corridor (Morris & Ferguson, 2006; Morris et al., 2009). Within these studies, Kenyan and Ugandan sex workers reported a relatively high proportion of condom use (77.0% of sex acts used condoms); however, mathematical modeling estimated that this level of inconsistent condom use could still contribute to 3200-4148 new HIV infections per year (Morris & Ferguson, 2006). Due to high mobility, there are many challenges associated with HIV service provision for truck drivers and sex workers. One analysis that compared the sex work venues in Kenya to those in Uganda, found that the bars and lodges in Kenya were more likely to have condom dispensers, sell condoms, and have more weekly condom distributions (Morris et al., 2009).   Workplace based interventions that include condom distribution and peer-outreach at the venues along truck stops could be an important strategy for risk reduction and one that aligns with current recommendations for interventions that are grounded in community empowerment (Moore et al., 2014).   One study documented the location where sex workers solicit and service clients and found that servicing clients indoors (i.e. sex workers own home, clients home, or hotel) compared to public   61 spaces significantly reduced the odds of physical violence from clients (Schwitters et al., 2015). There were no prevalence estimates for solicitation or service venues reported in this study.   Of note, there were no studies of sex workers from any of the northern Provinces. As northern Uganda has been heavily affected by war, it is a vulnerable environment where sex workers are likely working but are difficult to access. There have been some studies investigating the informal practice of transactional sex (Lees et al., 2014; Patel et al., 2014; Rujumba & Kwiringira, 2010) and sex trafficking/slavery within the LRA (Mckay, 2004; Oosterhoff, Mills, & Oosterom, 2014; Westerhaus, 2007). However, there were no quantitative studies that investigated formal commercial sex work environments, and this is an important omission because of the fragile nature of regions that are currently experiencing or recovering from violent conflict.   2.4.2 Commercial and non-commercial violence against sex workers There was one study documenting violence against sex workers in Uganda (Schwitters et al., 2015) and found high levels of commercial violence from clients (<80%) and non-commercial violence from intimate partners (18.2%), friends (8.2%), authority figures (3.4%), and family members (2.1%). This study was the only quantitative study to document the high burden of violence against sex workers from multiple sources.  Qualitative studies among sex workers in Uganda consistently documented that a serious threat to health and safety among sex workers was violence from clients, including physical and sexual assault, rape and gang rape (Mbonye et al., 2013; Ntozi et al., 2003; Nyanzi, 2013; Schoemaker   62 & Twikirize, 2012; Scorgie et al., 2013). In addition to being a serious human rights abuse, violence and fear of violence from clients is associated with increased risk of HIV infection and reduced condom use (Decker, Pearson, et al., 2013; Okal et al., 2011). The limited availability of epidemiological information on violence against sex workers and violence within the non-commercial aspects of their lives is an area that requires further investigation in Uganda. The integration of violence prevention into comprehensive HIV programming has been shown to be an effective and important strategy, both to reduce risk of HIV and to improve general health and safety for sex workers (Beyrer et al., 2014; Chersich et al., 2013; Moore et al., 2014).    There were no quantitative studies reporting on the prevalence or experience of policing. This is an important gap as sex work is considered a criminal offence in Uganda. Qualitative studies among sex workers in Uganda have documented the common occurrence of police harassment, including arbitrary arrest, degrading treatment, and physical and sexual violence (Mbonye et al., 2012, 2013, 2014; Nyanzi, 2013; Scorgie, Nakato, et al., 2013; Scorgie, Vasey, et al., 2013). Given the global consensus that the criminalization of sex work is one of the largest structural determinants increasing the risk of HIV among sex workers (World AIDS Campaign, 2010), ongoing documentation of the effects of policing and criminalization of sex work is needed. International policy bodies have specifically called for the removal of criminal laws targeting sex work as necessary for both HIV prevention and the protection of human rights (Beyrer et al., 2011; Decker et al., 2014; Kerrigan et al., 2014).     63 2.5 Limitations The limitations of this review must be acknowledged. First, as this review was designed to assess and synthesize research with quantitative results among sex workers in Uganda, qualitative studies were not included. Qualitative studies are a necessary component of understanding the contextual and region-specific challenges that sex workers face and are essential to design epidemiological studies that can quantify risks and factors that impede HIV prevention. In the review process, 13 studies with qualitative methodology were identified and a summary of the results has been included in Appendix B and the results are discussed within this chapter. Second, it is likely that the included studies have limited generalizability to sex workers from other settings. An important gap identified in this review is the lack of regional distribution; as a result, these studies primarily summarize research from Kampala and along the trans-Africa highway and are not generalizable to other regions of Uganda. Additionally, three studies originated from a clinical trial assessing the effectiveness of vaginal microbicides and self-report measures of condom-use were very high and potentially skewed because of reporting bias. Third, this review did not formally evaluate the quality of evidence in the primary research presented and the relative weight of evidence was not conducted. This does allow for a greater range of study designs and methodologies to be included and has allowed for the inclusion of studies that cover behavioural, social, and clinical epidemiology.  2.6 Conclusion This systematic review describes the extent of the epidemiological research on sex workers in Uganda and documents multiple risk factors that contribute to the heightened burden of HIV/STIs among sex workers including challenges with consistent condom use and access to   64 care and services. There was limited information on socio-structural factors that affect sex workers’ commercial working environments, including the role of policing and criminalization, as well as the prevalence and factors associated with violence from clients. The majority of the existing evidence comes from sex workers in Kampala, highlighting a need for information on sex work in other regions of Uganda, including the northern provinces with heightened risks associated with violent conflict. Additionally, there is little information on features of the non-commercial components of sex workers’ lives as well as the services needed to reduce risks outside of the sex industry.     65 Chapter 3: Commercial violence against sex workers: High burden of client perpetrated violence among sex workers in conflict-affected northern Uganda  3.1 Introduction Violence is one of the leading causes of morbidity and mortality amongst women globally, with substantial variation in the type, incidence, and prevalence of violence between different regions of the world, and within sub-populations (Mercy, Butchart, Rosenberg, Dahlberg, & Harvey, 2008). The International Labour Office (ILO) has identified the prevention and eradication of workplace violence as a priority for achieving gender equality and social protection, with renewed emphasis on marginalized populations in the informal sector including migrants and adult consensual sex workers (Cruz & Klinger, 2011). The shift to include adult consensual sex work is a newly specified area. Much of the sexual labour-related research to date has focused on the detrimental effects of sex trafficking, creating widespread and destructive conflation of sex trafficking (e.g., forced sexual labour) with adult consensual sex work and the importance of safer sex work environments (Decker, 2013).   The combined public health burden of physical and sexual workplace violence and HIV/STIs are concerns for sex workers around the world (Decker, Wirtz, et al., 2013; Karim et al., 1995; Okal et al., 2011). A survey of sex workers in Kenya reported that more than 35% of sex workers had been raped and 17% had been physically assaulted by clients within a 30-day recall period (Elmore-Meegan et al., 2004). A study in Namibia found that more than 18% of sex workers had reported abuse from clients and 9.0% from police (Hubbard & Zimba, 2003). Studies among sex workers in Togo and Burkina Faso found that 18.0% had reported violence from regular clients,   66 34.5% from new clients, and 12.1% from police in the previous year (Wirtz et al., 2015). Studies among sex workers in Benin found a high burden of violence within the previous month where 17.2%, 13.5%, and 33.5% of sex workers had experienced physical, sexual, and psychological violence respectively (Tounkara et al., 2014). Despite these findings, the concepts of workplace violence and occupational health and safety in sex work remain under-examined (Ross, Crisp, Månsson, & Hawkes, 2012).   Many global governing bodies have declared that the criminalization of sex work is the strongest structural determinant influencing the health and safety of sex workers (World Health Organization, 2014). Under a criminalized framework, sex workers are unable to seek protections from police despite experiencing high levels of violence and human rights abuses. Some studies have also documented police perpetrated violence against sex workers, including physical and sexual violence, and harassment through extortion or bribes (Chersich et al., 2013; Okal et al., 2011; Popoola, 2013; Richter et al., 2010; Richter, Chersich, et al., 2014; Scorgie et al., 2011; Scorgie, Vasey, et al., 2013). To avoid contact with police, sex workers report moving to more isolated and dangerous areas where they have less power to negotiate terms with clients (Beyrer et al., 2014).    Uganda, as with a number of other countries in sub-Saharan Africa, has recently come under fire after imposing harsh criminalization penalties for marginalized communities, including sex workers and sexual minorities, and in 2014 several countries and international organizations have cut aid or loans to Uganda by $118 million (United Nations Department of Economic and Social Affairs, 2014). While the link between criminalization and violence among sex workers   67 has been acknowledged globally and highlighted by global policy bodies and Ugandan human rights activists alike, epidemiological data on the prevalence and kinds of violence against sex workers in Uganda is needed.   Currently, there is limited information on the experiences of sex workers living and working in conflict-affected areas and how state instability may shape risks associated with violence and HIV. Conflict-affected environments can experience heightened risks associated with HIV including: mobile armed forces, displaced and mobile populations, congested camp settings, complex sexual networks, constrained or completely halted economies, limited food and resources, and general insecurity and violence (Doocy, Tappis, Haskew, Wilkinson, & Spiegel, 2011; Muhwezi et al., 2011; Mulumba, 2011; Spiegel & Harroff-Tavel, 2006). The AIDS, Security, and Conflict Initiative (ASCI) was developed in 2005 to address the intersecting concerns of state fragility and HIV prevention. ASCI’s 2010 recommendations include integrated HIV prevention programming that include major reform to policing and law enforcement, stating that the policing of sex work directly influences the trajectory of national and regional HIV epidemics (de Waal et al., 2010). In response to the synergistic effects of violence and HIV, the integration of human security and epidemic control is now a mainstream discussion for foreign ministries and international agencies (de Waal et al., 2010). While these recommendations were important for acknowledging the presence of sex work in conflict-affected settings, an evidence gap remains regarding the conditions and risks experienced by sex workers living in conflict-affected settings, including identifying areas for intervention.     68 The current study examines the prevalence of recent physical and/or sexual workplace violence among sex workers, and investigates the specific association between policing and client violence in addition to a broad range of individual and structural level factors.   3.2 Methods 3.2.1 Procedures Data for this analysis come from a cross-sectional study of HIV prevention, treatment, and care among 400 young sex workers living in northern Uganda (May 2011-January 2012). Study eligibility criteria included: being 14 years or older and having exchanged sex for money or resources (e.g., food, childcare, shelter, cell phone air time) in the previous 30 days. Extensive outreach and engagement with communities, sex workers, NGOs, and other health services were undertaken by an Acholi research team including both sex workers and non-sex worker service providers. Participants were recruited through the TASO clinic and peer/sex worker-led outreach to hotspots (e.g., bars and hotels) where sex workers worked, as well as weekly TASO outreach to former IDP camps (i.e., Pabbo, Bobi, Awach, and Labongogali). Structured interview-administered questionnaires and opt-in voluntary HIV counselling and testing (HCT) were conducted. See section 1.10 for a detailed description of the study procedures.   3.2.2 Data collection Study questionnaires were first developed in English and then adapted by the Gulu study team and translated into Luo. The Luo versions were piloted with a group of Acholi sex workers that provided feedback on the appropriateness of the questions and added new questions they found important to the northern Ugandan context. Study questionnaires collected information on   69 demographics, sex work histories and current working environments, intimate partnerships, trauma and violence (including war related violence and abduction), sexual and reproductive health, and HIV prevention, treatment, and care. The study was explained verbally in Luo and each participant received a copy of the consent form. Participants provided written informed consent or provided a thumbprint in the case of limited literacy.   3.2.3 Measures 3.2.3.1 Dependent variable The six-month period prevalence of client violence is a composite outcome derived from a checklist of common adverse and physical and/or sexual violent experiences perpetrated by clients in the past six months (based on piloting and consultation with sex workers in Gulu). Participants were coded as experiencing physical and/or sexual workplace violence from clients if they reported any of the following: physical assault, attempted sexual assault, rape, gang rape, locked in a car, abducted/kidnapped, thrown out of a moving car, strangled, assaulted with a weapon or genital mutilation from clients. This group was compared to those who did not experience sexual or physical violence but may have reported verbal harassment, being robbed/not paid by a client, client condom refusal or no violence.  3.2.3.2 Independent variables All work environment variables were temporally restricted to the last six months. The following sex work solicitation venues were investigated: bar (yes vs. no), lodge (yes vs. no), or highway/truck stop (yes vs. no),). Service venues included bars, (yes vs. no), lodges (yes vs. no), client’s place (yes vs. no), own place (yes vs. no) or highway/truck stop (yes vs. no). A variable   70 was derived to compare sex workers who reported inconsistent condom use with clients (including any unprotected vaginal or anal intercourse with one-time or regular clients) to those who reported consistent condom use for all sex work transactions. This variable has been shown to be a known risk factor associated with client violence (Deering et al., 2014).  Sex workers also reported on access to condoms, having a sugar daddy (locally defined as having a sexual partner the same age as a father figure), working for/with a manager, pimp or administrator (defined as sharing a percentage of your income with a manager, pimp or other administrator), rushed negotiations with a client due to police presence, and lifetime police arrest.   Demographic variables included in the analysis were age (continuous) and education (dichotomized to represent less or more than primary education). Tribal identity compared Acholi versus other tribes in northern Uganda (e.g., Teso and Lango). A dichotomous variable was derived to compare those with and without dependent children. Data on orphan status compared those who lost one or both parents (single/double orphans) to those with both parents alive. Conflict related characteristics included a history of living in an internally displaced persons (IDP) camp or having been abducted by the LRA.  3.2.3.3 Data analyses Analyses were performed using SAS (version 9.3). Chi-square tests of association were used to identify statistical differences in demographic, sex work environment, and conflict-related variables between those who had experienced client violence and those who had not. Bivariable logistic regression was used to examine the strength of association between each of the explanatory variables and recent client violence.    71  Multivariable logistic regression analyses included variables determined to be statistically significantly associated with client violence at the bivariable level. The Akaike’s Information Criterion (AIC) was used to inform selection of the most parsimonious model. The final model was assessed for multicollinearity using the Eigenvalue and proportion of variation. Variables selected for the final multivariable model are considered factors most strongly associated with client violence.  3.3 Results 3.3.1 Descriptive characteristics Within the sample of 400 sex workers, 196 (49.0%) had experienced physical or sexual violence from clients in the previous six months. Table 3.1 displays the prevalence of each type of client violence experienced in the previous six months. Among the 196 sex workers who reported client violence, the most common forms included being physically assaulted (58.7%), raped (38.3%), the client attempting sexual assault (18.4%), and being gang raped (15.8%).  The median age of the participants was 21 years (interquartile range (IQR): 19-25 years), 369 (92.5%) were from the Acholi tribe, 298 (74.5%) reported having one or more children, and 255 (63.8%) had completed less than primary school education. A total of 135 women were HIV positive, a HIV prevalence of 33.8%. Within the sample, 66.5% had lived in an IDP camp and 31.1% had been abducted by the LRA. There were no significant demographic or conflict-related differences between those who had or had not experienced client violence.    72 Table 3.1: Types of violence among 196 sex workers in Gulu, northern Uganda who experienced client violence in the previous six months Table 3.1 Types of violence among 196 sex workers in Gulu, northern Uganda who experienced client violence in the previous six months   Types of client violence N=196*  (%) Physically assaulted 115 (58.67) Raped 75 (38.27) Attempted sexual assault 36 (18.37) Gang rape 31 (15.82) Locked in a car 27 (13.78) Abducted/kidnapped 23 (11.73) Thrown out of a moving vehicle 22 (11.22) Strangled 16 (8.16) Assaulted with a weapon 14 (7.14) Genital mutilation 8 (4.08) *The 6-month prevalence of client violence was 49.0% (196/400)    The most common places that sex workers solicited for clients were in bars (90.8%), along highways/truck stops (65.0%), and in hotels/lodges (50.8%). The most common places to service clients were hotels (87.3%), the client’s place (70.3%), and the sex worker’s own space (51.3%). Nearly all respondents (84.0%) reported inconsistent condom use with regular or one-time clients. Significant differences were observed for several work environment variables, including: soliciting in a hotel/lodge, servicing clients in a bar or highway/truck stop/outdoors, inconsistent condom use with clients, having a manager or pimp, and rushing negotiations because of police presence. See Table 3.2.   3.3.2 Bivariable analyses Table 3.3 displays the bivariable associations with physical and/or sexual workplace violence by a client. Variables significantly associated with physical and/or sexual workplace violence at the bivariable level included servicing clients along the highways/truck stops    73 Table 3.2: Sample characteristics of sex workers in Gulu, northern Uganda who experienced client violence in the previous six months compared to those who have not (n=400)    Recent Client Violence   Total n=400 Yes n=196 No n=204  p-value Socio-demographic      Age (med, IQR) 21 (19-25) 21 (19-25) 21 (19-26) 0.268 Ethnicity: Acholi (yes vs. no) (n=1)1 369 (92.5) 181 (92.4) 188 (92.6) 0.920 Less than primary (yes vs. no) 255 (63.8) 122 (62.2) 133 (65.2) 0.540 Has dependent children (yes vs. no) 298 (74.5) 147 (75.0) 151 (74.0) 0.822 Age at first sex (med, IQR) (n=2)     Orphan (single/double) (yes vs. no) (n=14) 337 (87.3) 165 (88.7) 172 (86.0) 0.425 HIV positive (yes vs. no)  135 (33.8) 61 (31.1) 74 (36.3) 0.276 Conflict related characteristics     Ever lived in an IDP camp (yes vs. no) 266 (66.5) 123 (62.8) 143 (70.1) 0.120 Abducted into the LRA (yes vs. no) (n=5) 123 (31.1) 60 (30.8) 63 (31.5) 0.875 Sex work risk environment     Place of solicit in last 6 months     Bar/Club (yes vs. no) 363 (90.8) 180 (91.8) 183 (89.7) 0.463 Hotel/Lodge (yes vs. no) 203 (50.8) 122 (62.2) 81 (39.7) <.001 Highway/Truck Stop/Outdoors (yes vs. no) 260 (65.0) 130 (66.3) 130 (63.7) 0.586 Place of service in last 6 months     Bar/Club (yes vs. no) 81 (20.3) 56 (28.6) 25 (12.3) <.001 Hotel/Lodge (yes vs. no) 349 (87.3) 170 (86.7) 179 (87.8) 0.762 Clients place (yes vs. no) 281 (70.3) 134 (68.4) 147 (72.1) 0.420 Own space (yes vs. no) 205 (51.3) 103 (52.6) 102 (50.0) 0.610 Highway/Truck Stop/Outdoors (yes vs. no) 41 (10.3) 32 (16.3) 9 (4.41) <.001 Inconsistent condom use     With one time clients (yes vs. no) (n=1) 304 (76.2) 137 (67.2) 167 (85.6) <.001 With regular clients (yes vs. no) (n=1) 317 (79.5) 168 (86.2) 149 (73.0) 0.001 With all clients (yes vs. no) (n=1) 335 (84.0) 179 (91.8) 156 (76.5) <.001 Client intoxicated (yes vs. no) (n=89) 124 (40.0) 62 (41.6) 62 (38.3) 0.548 Trouble accessing condoms (yes vs. no) (n=3) 222 (55.9) 110 (56.4) 112 (55.5) 0.847 Has a ‘sugar daddy’ (yes vs. no) (n=2) 344 (86.4) 176 (89.8) 168 (83.2) 0.056 Manager/Pimp in last 6 months (yes vs. no) 100 (25.0) 67 (34.2) 33 (16.2) <.001 Rushed negotiations because of police presence (yes vs. no) 149 (37.3) 92 (46.9) 57 (27.9) <.001 Weekly income (UGX) from sex work2 (med, IQR) (n=7) 40,000 (25,000-70,000) 50,000 (30,000-80,000) 40,000 (20,000-60,000) 0.678 History of incarceration (yes vs. no) 106 (26.5) 58 (29.6) 48 (23.5) 0.170 1 denotes missing values; 2 40,000UGX is approximately 15 USD    74  (OR:4.23,95% CI: 1.96-9.11), inconsistent condom use with any client (OR:3.44, 95% CI: 1.88-6.31), servicing clients in a bar (OR: 2.86, 95% CI: 1.70-4.82), having a pimp or manager (OR: 2.69, 95% CI: 1.67-4.33), soliciting for clients in hotel/lodges (OR: 2.50, 95% CI: 1.67-3.74), and rushing negotiations with clients because of police presence (OR: 2.28, 95% CI: 1.51-3.46).   Table 3.3: Bivariable and multivariable associations for the correlates of client violence in the previous six months among sex workers in Gulu, northern Uganda (n=400)  Table 3.3: Bivariable and multivariable associations for the correlates of client violence in the previous six months among sex workers in Gulu, northern Uganda (n=400)    Recent Client Violence Variables OR 95% CI AOR 95% CI Sex work risk environment     Place of solicit in last 6 months     Bar/Club (yes vs. no) 1.29 0.65-2.55 -  Hotel/Lodge (yes vs. no) 2.50 1.67-3.74 -  Highway/Truck Stop/Outdoors (yes vs. no) 1.12 0.74-1.69 -  Place of service in last 6 months     Bar/Club (yes vs. no) 2.86 1.70-4.82 2.07 1.19-3.59 Hotel/Lodge (yes vs. no) 0.91 0.51-1.64 -  Clients place (yes vs. no) 0.84 0.55-1.29 -  Own space (yes vs. no) 1.11 0.75-1.64 -  Highway/Truck Stop/Outdoors (yes vs. no) 4.23 1.96-9.11 -  Inconsistent condom use with any client (yes vs. no) 3.44 1.88-6.31 2.87 1.54-5.35 Has a ‘sugar daddy’  (yes vs. no) 1.78 0.99-3.22 -  Manager/Pimp in last 6 months (yes vs. no) 2.69 1.67-4.33 2.05 1.24-3.39 Rushed negotiations because of police presence (yes vs. no) 2.28 1.51-3.46 1.61 1.03-2.52    75  3.3.3 Multivariable analyses In multivariable analyses, factors independently associated with physical and/or sexual workplace violence included inconsistent condom use (AOR: 2.87, 95% CI: 1.54-5.35), servicing clients in a bar (AOR: 2.07, 95% CI:1.19-3.59), working for a manager or pimp (AOR: 2.05, 95% CI: 1.24-3.39), and rushing negotiations with clients because of police presence (AOR: 1.61, 95% CI: 1.03-2.52).   3.4 Discussion This study documents a high burden of violence among sex workers in conflict-affected northern Uganda, with almost 50% experiencing extreme physical and/or sexual workplace violence in the previous six months, including physical assault, rape, and gang rape. Rushing negotiations because of police presence contributed to 60% higher odds of client violence, a finding that highlights the dangerous consequences of criminalization and associated policing practices. Additional labour-based factors that contributed to increased exposure to client violence included inconsistent condom use with clients, working with a pimp/administrator, and servicing clients in bars.   A deeply disturbing finding within this analysis is that 31 (15.82%) women reported being gang raped in the previous six months. Qualitative studies from sex workers in Kenya, Uganda, Zimbabwe, and South Africa have documented the common occurrence of gang rape from both clients and police officers. This was reportedly more common among poor men who could not afford to pay individually and would pool their money to buy sex from a sex worker and then   76 share (Scorgie, Vasey, et al., 2013). Studies among the general population of women living in conflict-affected areas in Sierra Leone, Democratic Republic of Congo, and Rwanda have reported the high prevalence of gang rape (Alison, 2007; Cohen, 2007; Kelly, Betancourt, Mukwege, Lipton, & Vanrooyen, 2011; Puechguirbal, 2008). A study among women in Sierra Leone found that over 75% of rape cases that were reported to the authorities were gang rapes (Cohen, 2007). The high prevalence of gang rape within this sample of sex workers living in a conflict-affected environment is potentially a combination of the criminalized sex work environment where client violence goes unpunished (Crago & Arnott, 2009) and the heightened sexual violence that is often reported in environment recovering from war (Kelly, Betancourt, Mukwege, Lipton, & Vanrooyen, 2011).  Within sub-Saharan Africa, sex work is criminalized in two-thirds of countries, including Uganda (World AIDS Campaign, 2010). It has been argued that the criminalization of sex work “is the single most powerful factor in making sex workers vulnerable to HIV” (World AIDS Campaign, 2010), and international policy bodies have specifically called for the removal of criminal laws targeting sex work as being necessary to both HIV prevention and the protection of human rights (Beyrer et al., 2011; Decker et al., 2014; Kerrigan et al., 2014). Given the high burden of HIV among sex workers in Uganda (Baral et al., 2012), the independent associations between policing and condom use in the increased odds of physical and/or sexual workplace violence are of major concern–particularly in a country with increasing attempts to criminalize sex workers.     77 Results from this analysis indicated that 149 (37.3%) sex workers reported rushing negotiations with clients because of police presence, which contributed to increased risk of violence from clients. Policing and criminalization have been shown to displace sex workers to isolated spaces and inhibit sex workers’ ability to report abusive clients, refuse clients unwilling to use condoms or seek legal recourse after experiencing physical or sexual violence (Crago & Arnott, 2009; de Waal, 2010a). Within the Ugandan Constitution, Ugandan police are mandated to “protect the life, property and other rights of the individual” (Government of Uganda, 1994). However, this analysis has shown that the policing of sex work may enable extreme acts of violence against sex workers, factors that directly and indirectly increase HIV risk. The criminalization of sex work in Uganda and elsewhere contradict best practices issued from the World Health Organization, United Nations, and other international conventions. In addition to the legislative change needed to structurally reform the legal environment (e.g., decriminalization of sex work), significant investments in training police officers and reorienting policing norms is a crucial component of transforming the police force into a protective resource for sex workers (Decker, Wirtz, et al., 2013).  Furthermore, criminalization limits sex workers’ access to labour and human rights protections, as noted by the ILO. Within this analysis, several labour-based issues were identified. Sex workers servicing clients in bars and working for a manager, pimp or other administrator (compared to working independently) were more likely to experience violence. Data from other international settings has highlighted the heterogeneous nature of work environments and pimp/management in sex work for mitigating violence and HIV risks, operating dynamically with legislative frameworks and policy supports. In Mexico, bars and entertainment venues with   78 management were considered more high risk work environments, as sex workers had reduced control over negotiating the terms of transactions with clients or accessing condoms and other protections (Gaines et al., 2013). In contrast, where sex workers have control over the transaction (including choice of clients, fee, and use of condoms), studies have shown that venues with management, bookkeepers or other administrators can serve a protective function (Urada et al., 2013). In sub-Saharan Africa, there remains a need for epidemiological and mixed methods research to better disentangle the role of policies, laws, and work environment features (e.g., access to condoms, control over transactions, and managerial practices) in influencing exposure to violence and HIV risks (Scheibe et al., 2012).   3.5 Limitations This analysis is one of the first quantitative studies to investigate the experiences of sex workers living in northern Uganda and it documents the magnitude of violence they experience from clients. The findings from this study are particularly in line with current efforts to decriminalize sex work as police presence was shown to positively increase the odds of client violence. A methodological limitation for this study is that it is cross-sectional in nature and the findings estimate the strength of association but are unable to establish causality. Secondly, self-reported experiences of sexual practices and violence are sensitive to social desirability bias. This risk was mitigated through the use of female Acholi research assistants, which likely increased the validity of the answers given; however, it is possible that having peer/sex workers trained as research assistants could improve the accuracy of the responses to the questions related to sex work. Thirdly, the results from this analysis may not be generalized to other areas of Uganda due to the heterogeneity of the sex worker population across the country as well as the variation in   79 terms of working and living environments (e.g., services provided, housing availability, and economic conditions).   3.6 Conclusion The results from this analysis demonstrate the dangerous association between policing and client violence among sex workers. The sex workers participating in this study experienced a high burden of workplace physical and/or sexual violence that was connected to reduced control over condom use and policing practices. Given the recent trends to further criminalize sex workers in a number of East and West African countries including Uganda, there is a need for a global policy response to ensure accountability by governments to ensure health and human rights for all. The global policy recommendations, including ILO, Global Commission on HIV/AIDS, WHO, and UNAIDS bodies, provide guidelines that need to be considered and implemented to reduce burden of both violence and HIV among sex workers in Uganda.      80 Chapter 4: Non-commercial violence against sex workers: LRA abduction and access to post-conflict reintegration programming among sex workers in conflict-affected northern Uganda  4.1 Introduction The empirical documentation of violence against sex workers has been important for contextualizing the complex challenges and human rights abuses that sex workers face. Common commercial forms of violence against sex workers include violence from paying clients, police, pimps/managers, and the general public. Extending beyond commercial forms of violence, non-commercial forms of violence have been shown to be important factors shaping the lives of sex workers, particularly their ability to reduce HIV risk (Decker, Pearson, et al., 2013; El-Bassel, Witte, Wada, Gilbert, & Wallace, 2001; Panchanadeswaran et al., 2008; Ulibarri et al., 2010).    Many studies have documented the common occurrence of intimate partner violence among sex workers, a factor that is associated with heightened exposure to HIV and difficulty negotiating condom use (Argento et al., 2014; Benoit et al., 2013; Decker, Pearson, et al., 2013; Jackson et al., 2009; Luchters et al., 2013; Muldoon, Deering, et al., 2014; Ngugi, Benoit, et al., 2012b; Panchanadeswaran et al., 2008). A second form of non-commercial violence that is common among sex workers is childhood trauma or abuse (El-Bassel et al., 2001; Grosso et al., 2015; Gu et al., 2013). Violence against children includes emotional, physical, and sexual abuse, and in some settings, can also include the worst forms of child labour such as abduction for the purpose of child soldiering (Stoltenborgh, Bakermans-Kranenburg, & van Ijzendoorn, 2013; UNICEF, UNHCR, Save the Children, & World Vision, 2012; UNICEF, 2014a). In conflict-affected   81 environments, child soldiers are defined as both boys and girls who are forced or abducted to serve with an armed group to fight as soldiers, act as cooks and porters, and some who are recruited for sexual purposes or forced marriage (Coalition to Stop the Use of Child Soldiers, 2008). Child soldiering is one of the most severe forms of childhood trauma and extensive resources, including adapted peace processes and targeted recovery programming, have been developed to support children who were abducted and forced to fight with armed groups (Betancourt, Agnew-Blais, Gilman, Williams, & Ellis, 2010; Betancourt et al., 2011; Blattman & Annan, 2010; Klasen, Reissmann, Voss, & Okello, 2014; Vindevogel, De Schryver, Broekaert, & Derluyn, 2013; Vindevogel et al., 2012).    As summarized in Section 1.6, the limited research within conflict-affected settings that investigates the lives of sex workers is predominantly focused on sexual and HIV risk and there is less information on commercial and non-commercial forms of violence (Aung et al., 2014; Larsen et al., 2004; Ntumbanzondo et al., 2006; Todd et al., 2010, 2011; Valadez et al., 2013). Childhood trauma is an important structural determinant affecting the lives of many sex workers (Shannon et al., 2014). In conflict-affected settings, child soldiering and abduction are extreme forms of childhood trauma that require intensive resources and specialized programming for recovery. Currently there is limited information on sex workers in conflict-affected areas, and even less investigation of historical exposure to war-related trauma.    82 4.1.1 Post-conflict programming for abductees: Disarmament, Demobilization, and Reintegration (DDR) programming  Disarmament, Demobilization, and Reintegration (DDR) is an applied strategy generally employed by all UN Peacekeeping Operations and is designed to provide amnesties and benefit or reinsertion packages to those that have been involved in mass atrocities as leverage to sign a peace agreement and disarm (UNDDR, 2012). Disarmament (i.e., physical removal of weapons and munitions) and demobilization (i.e., disbanding of armed groups) are well defined and occur relatively immediately in peace processes (UNDDR, 2012). Disarmament and demobilization are commonly implemented by national governments and multilateral agencies with the goal to foster conditions for sustainable investment and good governance, and to ultimately provide stability for transitional justice mechanisms to operate (Muggah, 2005).    Reintegration is the process whereby former combatants and abductees acquire civilian status and support services to reintegrate into post-conflict society (Inter-Agency Working Group on DDR, 2006). It is a complex and open-ended process between the combatants, abductees, and the recipient community that cannot be imposed or centralized. As written by De Vries (2011), “one cannot ‘programme’ people into accepting one another after years of violent conflict” (De Vries & Wiegink, 2011). The objectives of reintegration programs are generally to provide support and opportunities to live “normal” lives, become a functional member of society, resume education, gain skills training, and reduce trauma, including anxiety and depression (UNDDR, 2012). Participation in armed groups is associated with exposure to extreme violence, and research has shown a higher frequency of trauma and mental illness among abductees compared to their non-abducted peers living through the same conflict (Pham et al., 2009). However, the specific kinds   83 of mental illness experienced remain an important area for further exploration. Reintegration of combatants and abductees is an essential component for establishing long-term stability for fragile states affected by conflict (Ochen, 2015).   Abduction or forced conscription of children has been documented in armed conflicts in Angola, Burundi, Democratic Republic of Congo, Mozambique, Rwanda, Somalia, Sudan, Sierra Leone, and Uganda (Silberman, 2000). In many contemporary African wars, girls and women participate in armed forces. However, the majority of ex-combatants are male. Fewer women and girls go through the official UN processes of DDR and continue to face substantial challenges in their physical and psycho-social recovery, including social ostracization, trauma, depression, and anxiety (Betancourt et al., 2011; Mckay, 2004; Vindevogel et al., 2015). Although sex and gender differences are increasingly acknowledged in conflict-affected settings, many studies often combine the experiences of women and girls with those of men and boys, subsequently limiting inference to female populations. Against this backdrop, young women in general and particularly young abductees continue to face large gender disparities in economic opportunities and access to education, including high rates of female illiteracy (United Nations, 2006)–all conditions that inhibit successful reintegration. The latest edition of the UN DDR guidelines have specifically called attention to the need for research to further understand and support the needs of women and girls affected by war (United Nations Department of Peacekeeping Operations, 2010). The inclusion of gender analyses is an important component of designing successful DDR programs, particularly to support the reintegration phase that takes the most time and is set against the backdrop of the gender inequities that often exist in the pre- and post-conflict society (Betancourt, Meyers-Ohki, Charrow, & Hansen, 2012; Mckay, 2004).   84  4.1.2 LRA abduction in northern Uganda DDR programs have featured prominently in the conflict-affected landscape of northern Uganda. The conflict between the Lord’s Resistance Army (LRA) and the Government’s Ugandan Peoples Defense Forces (UPDF) lasted over two decades, during which it is estimated that between 25,000 and 60,000 youth between the ages of 13 and 30 were abducted into the LRA (Blattman, 2006). Different documents report increased frequency of abduction into the LRA corresponding to historical events during the war including the two government-led military offensives, Operation North (1991) and Operation Iron Fist (2002), and a high-profile event in the town of Atiak in 1995, where the LRA massacred over 300 civilian men and boys (Justice and Reconciliation Project, 2007) and abducted hundreds of girls from schools in the surrounding area (Nyakairu, 2008). The frequency of children abducted over the course of the war was documented by Amnesty International and Human Rights Watch (Berkley-Tulane Initiative on Vulnerable Populations, 2007; Human Rights Watch, 2003). However, few other studies have investigated the frequency of abduction among their samples and how they correspond to the historical progress of the war in Uganda.  The DDR operation in northern Uganda had the first task of disarming and demobilizing the LRA (Annan, Brier, & Aryemo, 2009; Blattman & Annan, 2006; De Vries & Wiegink, 2011). Under the Amnesty Act, any Ugandan citizen involved in the insurgency against the UPDF since 1986 was eligible for amnesty and to participate in DDR programs. The Amnesty Act was reified in 2000; however, the Amnesty Commission only began providing certificates and aid to combatants that returned after 2000. When reporters apply for amnesty, they commonly register   85 at reception centres, a halfway house between rebel life and civilian life (Borzello, 2007). It was reported that NGO and government reception centres were able to offer some level of counselling, education, and skills training (Borzello, 2007). However, it is estimated that over 25% of returnees did not report to the authorities (Borzello, 2007) and only 13% of registered abductees received a follow-up visit from the reception centre (Allen & Vlassenroot, 2010). Evidence to support access to reintegration programming and evaluations of the association between accessing reintegration programs and health outcomes, including mental health, remain an important gap in the literature (Betancourt, Borisova, et al., 2012; Mckay, 2004; Vindevogel et al., 2015).   4.1.3 Objectives Northern Uganda is a complex political and social environment recovering from a civil war where thousands of young women were abducted into the LRA. Female abductees are highly exposed to violence, poverty, and trauma, all considered to be structural determinants that shape their current health and safety. Additionally, there are many young women engaged in sex work in northern Uganda who are disproportionately exposed to workplace violence from clients, police, pimps, and the general public. There is currently limited information regarding the proportion of sex workers with historical exposure to war, particularly LRA abduction. This current analysis was designed to investigate non-commercial forms of violence with the specific focus of conflict-related experiences including LRA abduction and access to reintegration programming.      86 Among a sample of sex workers, the objectives for this analysis were to: (1) describe a sample of female former abductees and explore abduction-related experiences including the frequency and duration of abduction over the timeline of the war; (2) determine the proportion of female participants that were able to access a reintegration program; (3) assess differences in mental health status among female former abductees who participated in a reintegration process compared to those did not.   4.2 Methods 4.2.1 Sampling and recruitment strategy Data for this analysis comes from a community-based cross-sectional study of HIV prevention, treatment, and care among 400 young sex workers in post-conflict transition phase in northern Uganda (May 2011-January 2012). Study eligibility criteria included: being 14 years or older and having exchanged sex for money or resources (e.g., food, shelter, cell phone air time, childcare) in the previous 30 days. This project was conducted in partnership with TASO Gulu and other community-based youth, women, sex work, and health service organizations. Participants were recruited through peer/sex worker-led outreach (former/current sex workers) to bars and hotels, where sex workers work, as well as community-led outreach to former IDP camps (i.e., Pabbo, Bobi, Awach, and Labongogali) together with The AIDS Support Organization (TASO) Gulu clinic. Study questionnaires collected information on demographics, sex work histories and current working environments, intimate partnerships, trauma and violence (including war related violence and abduction), sexual and reproductive health, and HIV prevention, treatment, and care. Structured interview-administered questionnaires and voluntary HIV counselling and testing (HCT) were conducted by Acholi research assistants and offered in the Luo language.   87 The analysis was restricted to 129 sex workers who self-reported being former abductees of the LRA. All variables are self-reported.  The methods are described in more detail in Section 1.10.  4.2.2 Measures Demographic variables included: age, educational attainment, ethnicity, biological children, and orphan status.   4.2.2.1 Abduction related variables Participants were asked their age at abduction and the year they were abducted, the length of time they remained in LRA captivity, and how they eventually departed. In the absence of a standardized measure, a literature review was conducted to identify common reintegration programs for war-affected populations. This list was supplemented by discussions with the research study team of Acholi staff. Participants were asked if they had participated in a reintegration process or program including any of the following: traditional cleansing ceremony, receiving an amnesty certificate, registration or lodging at a reception centre or receiving a reinsertion package.   A traditional cleansing ceremony is a public form of reintegration and restorative justice that is facilitated by a clan elder with the intention to prepare the communities to accept abductees and former rebels back into society. The ceremony is a process designed to cleanse the returned person of any crimes they may have committed or negative experiences they went through   88 during captivity (Justice and Reconciliation Project, 2012). Abductees or former rebels were granted amnesty if they presented themselves at a government authority and renounced all involvement in the war and surrendered any weapons. Their file was reviewed by the Amnesty Commission and a Certificate of Amnesty was issued (Allen & Schomerus, 2006; Annan, Blattman, Carlson, & Mazurana, 2007). Reception centres were typically run by non-governmental organizations that provided basic medical care, psychosocial support, and family relocation services (Annan, Blattman, Mazurana, & Carlson, 2011). Reinsertion packages often included receiving a small monetary stipend and a kit of items including a mattress, blanket, pots, pans, and cutlery (Annan et al., 2011).  Those who reported that they had not participated in any form of reintegration were classified as abductees who self-reintegrated, while the rest were classified as abductees who accessed reintegration programming. A dichotomous variable was derived to compare those who had a child with a LRA member to those who had not.  4.2.2.2 Mental health The mental health status was assessed using a locally-developed and validated scale called the Acholi Psychosocial Assessment Instrument (APAI) (Betancourt, Bass, & Borisova, 2009). The APAI was developed using free listing interviews with youth, local adults, and key informants to identify and describe signs of mental health syndromes affecting Acholi youth (Betancourt et al., 2009). The APAI scale includes 60 locally identified signs and symptoms on a likert scale from 0 (never) to 3 (constantly), and has been validated with strong test-retest and inter-rater reliability (Betancourt et al., 2009). The APAI scale has been successfully used to evaluate the   89 effectiveness of interventions for depression symptoms among adolescent survivors of war and displacement in northern Uganda (Betancourt, 2008; Betancourt, Newnham, et al., 2012; Bolton et al., 2007; Verdeli et al., 2008). This study uses one depression sub-scale capturing indicators for the local syndrome termed Kumu. The anxiety subscale captures indicators of the local syndrome termed Ma lwor. The scores on the depression sub-scale range from 0-39 and include statements such as “I feel a lot of pain in my heart.” and “I sit with my cheek in my palm.” The scores on the anxiety sub-scale range from 0-36 and include statements such as “I think people are chasing me.” and “I have fast heart rate.” The means from each sub-scale were used to assess differences in mental health status among former abductees who participated in a reintegration process compared to those who have not. The APAI scale was designed to assess relative between groups differences in mental health and cannot be used for the purposes of diagnosing depression or anxiety.   4.2.3 Data analyses Statistical analyses were performed using SAS (version 9.3). Descriptive statistics (frequencies for dichotomous and categorical variables, and medians and interquartile ranges (IQR) for continuous variables) were used to display the distribution of the outcome (mental health), exposure (re-integration status) and other variables. Each abductee reported the year they were abducted, and the abduction frequencies were displayed with a histogram against the historical timeline of the war in order to explore fluctuations of abduction frequencies against key events in the war including UPDF military operations, the Atiak massacre, the reification of the Amnesty Act, and the ceasefire signed between the LRA and the Government.     90 A post-hoc analysis was conducted to test for group differences in mental health status between abductees who accessed a reintegration program versus those who self-reintegrated. A t-test was used to compare the means of the APAI depression sub-scale (kumu) and the anxiety subscale (ma lwor). Less than 5% of cases (n=6) had missing data on the APAI scale. To avoid case deletion, a conservative value of zero was imputed, a technique that biases the results towards the null. A sensitivity analysis was used to assess if there were significant difference between the sample with complete cases (n=123) compared to the sample with imputed values (n=129).   The study received ethical approval from the University of British Columbia Behavioural Research Ethics Board and The AIDS Support Organization (TASO) Institutional Review Board (IRB), and the protocol is registered at the Ugandan National Council for Science and Technology (UNCST).   4.3 Results Among the sample of 400 female sex workers, a total of 129 (32.2%) had been abducted by the LRA and were included in this analysis. The characteristics of abductees in this sample are presented in Table 4.1. The median age of the study participants in this study was 22 years (IQR: 20-26) and participants were predominantly from the Acholi tribe (96.1%). Almost 70% had less than primary education. The majority of the sample (85.3%) were either single or double orphans.   The majority of the sample (83.7%) had lived in an IDP camp at some point during the war. When asked about their experiences with abduction, participants reported that they were   91 abducted at the median age of 13 years (IQR: 11-14) and the majority were abducted between 1998-2005. Some had been abducted for less than three days, however 23.9% had been abducted for more than a year. Table 4.1: Characteristics of sex workers with a history of abduction (n=129) who accessed a reintegration program compared to those who did not Table 4.1 Characteristics of sex workers with a history of abduction (n=129) who accessed a reintegration program compared to those who did not   Total Reintegration Programming Variables n(%)2 (n=129) Yes (n=56) No (n=73) Socio-demographic     Age (med, IQR) 22 (20-26) 20.5 (19-25) 23 (20-28) Tribe: Acholi (yes vs. no) 124 (96.12) 52 (92.86) 72 (98.36) Less than primary (yes vs. no) 90 (69.77) 37 (66.07) 53 (72.60) ! 1 Biological child (yes vs. no) 107 (82.95) 41 (73.21) 66 (90.41) Orphan (single/double) (yes vs. no) (n=7)1 104 (85.25) 44 (86.27) 60 (84.51) Living with HIV (yes vs. no) 53 (41.09) 31 (44.64) 28 (38.36) Sex Work Risk Environment    Age at first sex work (med, IQR) (n=2) 18 (15-20) 17 (16-20) 18 (15-20) Weekly income from sex work (med, IQR) 3 (n=4) 40,000 UGX  (20,000-60,000) 40,000 UGX  (20,000-60,000) 40,000 UGX  (20,000-70,000) War related variables    Ever lived in an IDP camp (yes vs. no) 108 (83.72) 46 (82.14) 62 (84.93) Age of Abduction (med, IQR) (n=8) 13 (11-14) 13 (10-14) 12 (11-15) Year of Abduction (med, IQR) 2002  (1998-2005) 2003  (1999-2006) 2001  (1996-2004) Period of Abduction     Less than 3 days 17 (13.18) 5 (8.93) 12 (16.44) 3-14 days 25 (19.38) 7 (12.50) 18 (24.66) 14-60 days 35 (27.13) 18 (32.14) 17 (23.29) 2-12 months 22 (17.05) 10 (17.86) 12 (16.44) ! 12 months 30 (23.26) 16 (28.57) 14 (19.18) Child with the LRA (yes vs. no) 18 (13.95) 11 (19.64) 7 (9.59) Manner of departure from LRA (n=2)    Escaped  98 (76.56) 45 (80.36) 53 (73.61) Released 20 (15.63) 7 (12.50) 13 (18.06) Rescued  9 (7.03) 4 (7.14) 5 (6.94) Reintegration program4    Traditional cleansing ceremony - 38 (67.86) - Amnesty - 21 (37.50) - Reception centre - 16 (28.57) - Re-insertion package - 7 (12.50) - 1 Variables with missing data are noted in parenthesis;2 Column Percentages;3 40,000 UGX is approximately 15USD;4 Categories not mutually exclusive     92  There were 18 (14.0%) participants who reported having a child with a LRA soldier. Figure 4.1 displays the frequency of abduction over selected events that punctuated the historical timeline of the war. Participants reported being abducted as early as 1989 and as late as 2010.  Figure 4.1: Variation in abduction frequency over the historical timeline of the war   When asked how they departed from the LRA, 76.6% of abductees reported that they escaped, 15.6% reported that they were released, and 7.0% reported that they were rescued. The majority (56.6%) of the sample did not access a reintegration process. For the 56 participants who had accessed reintegration programming, the most commonly reported program was a traditional cleansing ceremony (67.9%), followed by receiving amnesty (37.5%), being registered or lodged   93 at a reception centre (28.6%), and receiving a re-insertion package (12.5%). The four reintegration programs are not mutually exclusive; however, only 16 of the 56 abductees accessed more than one kind of reintegration program. The cell sizes were not large enough to discern patterns in the combinations of accessed programs. Almost 25% of the sample reported being abducted in 2004, between Operation Iron Fist (2002) and the 2006 ceasefire agreement.  Overall, the total score on the APAI was 20.34 (sd=8.96). The score for the depression sub-scale Kumu was 12.84 (sd=4.79) and anxiety sub-scale Ma lwor was 8.76 (sd=5.14). Table 4.2 displays the mean scores on the APAI total and subscales. Among this sample of abductees, significant differences in mental health status were not detected between those who accessed any kind of reintegration programming compared to those who self-reintegrated. The mean scores on the APAI total and the anxiety and depression sub-scales were not significantly different between those who had participated in a reintegration program and those who self-reintegrated (p<0.05). Sensitivity analyses suggest that there were no significant differences between participants with missing data and the sample with imputed values.   4.4 Discussion The results from this study showcase the experiences of abduction among young women who are currently involved in sex work. The majority of abductees in this study were abducted at a young age (median 13 years) over the course of the war (1989-2010). Almost 25% of participants reported being abducted in 2004, in-between Operation Iron Fist in 2002 and the ceasefire in 2006.     94  Table 4.2: APAI descriptive statistics and between group test of means among sex workers with a history of abduction who accessed reintegration programming compared to those who did not (n=129) Table 4.2: APAI descriptive statistics and between group test of means among sex workers with a history of abduction who accessed reintegration programming compared to those who did not (n=129)   Total  Reintegration Programming  p-value   (n=129) Yes  (n=56) No (n=73)  APAI Total     mean 20.34 20.67 20.09 0.562 standard deviation 8.96 9.36 8.69  range 3-40 4-40 3-37  Depression - Kumu     mean 12.84 13.18 12.58 0.484 standard deviation 4.79 5.04 4.60  range 3-27 4-27 3-24  Anxiety - Ma Lwor     mean 8.76 8.75 8.76 0.990 standard deviation 5.14 5.47 4.19  range 0-19 0-19 0-19     This analysis provides descriptive information on the different kinds of reintegration programming that young female abductees accessed in the past and evaluated between-group differences in current mental health.  This study documents that just over half (52.7%) of this sample of abductees were able to access some form of reintegration program, a figure that is consistent with estimates from other studies (Allen & Schomerus, 2006; Annan, Blattman, Carlson, & Mazurana, 2008). The most commonly reported form of reintegration programming was participating in a traditional cleansing ceremony, followed by receiving amnesty, being received at a reception centre, and receiving a   95 re-insertion package. Significant differences in mental health status were not detected between those who had accessed at least one kind of reintegration program compared to those who self-reintegrated. These results, and the cross-sectional design of this study, are not able to infer that reintegration programming causally affects mental health. However, a contribution that this analysis is able to offer is an exploratory investigation into between group comparisons. In contrast to studies in the literature that have focused on abductees already registered at reception centres (Allen & Schomerus, 2006; Vindevogel et al., 2011), this study utilized the opportunity to compare abductees who accessed reintegration services to those who reintegrated without programming, but did not find significant differences. Additionally, this study presented information on young female abductees who are less represented in the literature.  Within this sample, a large proportion (56.6%) of abductees reintegrated without programming. One possible explanation for the gaps in access to reintegration services could be explained by the variation in frequencies of abduction and return over the course of the war. This has been linked to the quantity and quality of services and has influenced the number of “reporters” reaching reception centres at different points during the war (Allen & Schomerus, 2006). For example, as a response to the government-led military offensives, Operation North in 1991 and Operation Iron Fist in 2002, the LRA was reported to have increased its frequency of abduction, which is reflected among this sample of abductees (Figure 4.1). Important events in the abduction history in northern Uganda were the LRA-led massacre in the village of Atiak, where over 300 civilians were murdered for suspected collaboration with the government, and an attack on the Atiak Girls School in 1996, where approximately 60 young women were abducted, a gender-specific increase in the frequency of abduction (Justice and Reconciliation Project, 2007).   96 The current analysis supports this reference as illustrated in Figure 4.1, where the abductions begin to rise in 1991 and reach their peak just before the ceasefire was signed in 2006. Peak periods of fighting between the UPDF and the LRA are also hypothesized to have increased the number of abductees that were able to use the opportunity to escape, thereby creating an influx of returnees at reception centres (Birkeland & Ridderbos, 2010; Borzello, 2007; Government of Uganda, 2010). Historically, after 2004, the number of returnees decreased and the immediate needs required for disarmament and demobilization began to shift to the long-term needs required for reintegration (Birkeland & Ridderbos, 2010; Borzello, 2007; Republic of Uganda, 2012). It is very likely that the reintegration experiences among abductees vary depending on the year that they escaped. Within our sample, most of the participants who were abducted and had accessed reintegration programming had been abducted in 2003, while those who reintegrated without programming were abducted in 2001. It is possible that the abductees who escaped before 2002 would have reintegrated during the immediate emergency phase, while those that returned in 2004 and after would have accessed more long-term programming.   Within the sample, over two-thirds of the abductees who accessed a reintegration program, also accessed a traditional cleansing ceremony (67.9%). Following a war, affected communities play key roles in cultural and social reconstruction (Mckay, 2004), and the high number of abductees able to access a traditional cleansing ceremony is encouraging (Ochen, 2015). The Survey of War Affected Youth (SWAY) found that only 22% of females abductees had accessed a traditional cleansing ceremony (Annan et al., 2008). However, the SWAY study was conducted in 2005 and it is possible that the current findings reflect the temporal trends in DDR programming over the evolution of the conflict beyond 2005 and perhaps increased effort to   97 include women and girls in DDR programming. An important barrier for traditional ceremonies are the associated costs, particularly for orphans who lack basic resources (Anyeko et al., 2011; Borzello, 2007). It is encouraging to see that, despite the large proportion of female single or double orphans (>85%) in this study, many still had access to traditional ceremonies. This is also demonstrative of the efforts that the local community invested in reintegration and reconciliation processes to establish relative peace.   The analysis in this study used the APAI scale to look for differences in mental health status between female abductees who accessed a reintegration program compared to those who self-reintegrated. While the APAI scale is not diagnostic, previous studies have documented that female abductees have higher levels of depression and anxiety-like symptoms compared to male abductees (McMullen et al., 2011) and this study adds to the literature describing mental health and wellness among female abductees. One of the goals of DDR programming is to improve psychosocial wellness (Inter-Agency Working Group on DDR, 2006) and a good deal of humanitarian aid is invested in reintegration programs with the intention that access to specialized supportive services can improve both short- and long-term well-being of abductees and combatants. However, the findings of the current analysis did not find significant differences between these two groups.   There are several factors that could be contributing to the null finding. For example, mental health status was evaluated many years after abduction, and is subject to confounding by the long-term challenges associated with reintegration including family reunification, mobilizing and enabling care services, schooling and vocational training (Accorsi et al., 2005; Henttonen, Watts,   98 Roberts, Kaducu, & Borchert, 2008; Horn, 2009; Nathan et al., 2004) that extend beyond exposure of access to the four types of reintegration programming examined in this analysis. Additionally, this is a sample of abductees identified through a study on young women involved in sex work. It possible that the current health and social disparities experienced by young sex workers in north Uganda, including high levels of violence, stigma and discrimination and heavy HIV burden, might overshadow the differences that could arise between reintegration programming versus self-reintegration.  The findings from this study are insufficient to make claims about the effect of reintegration programs, however they do begin to describe access to programming and offer a preliminary investigation into current mental health status. Furthermore, it is possible that in this particular setting the demand for or the effects of more formal reintegration programs may have been washed out by high levels of informal supports including those provided through family and community (Betancourt, Agnew-Blais, et al., 2010; Betancourt, Brennan, Rubin-Smith, Fitzmaurice, & Gilman, 2010; Betancourt, Borisova, et al., 2010; Joireman, Sawyer, & Wilhoit, 2012).   Much of DDR programming is focused on the critical first step of military disarmament and demobilization and because most military personnel are men, women have been underrepresented in the response and empirical literature. The current study found that approximately 45% of female abductees in this sample were able to access a reintegration program, including formal processes such as Amnesty International and traditional cleansing ceremonies. Young women were abducted in their early teens and stayed on average for 12 months in captivity. The results from this current study could help inform new developments in DDR policy and programming in conflict-affected settings. The United Nations Department of   99 Peacekeeping Operations has specifically identified a lack of evidence to inform programming for women and girls involved in forced conscription. The findings from this current study support the need to develop programs that are sensitive to both age and gender for women and girls returning from captivity.   4.5 Limitations This study has several limitations that should be taken into consideration when interpreting these findings. First, the analytic sample was restricted to 129 abductees who also had engaged in sex work in the past 30 days. While there is no reason to assume differences in the likelihood the two groups (abductees who had reintegrated without programming and abductees who had reintegrated through formal programs) had engaged in sex work, these findings may not be generalizable to all abductees (e.g., those abductees who are not also sex workers). A second limitation with this analysis is the heterogeneity of the composite reintegration variable. The four different kinds of reintegration programs included in this analysis vary in nature and length.  They range from community-based traditional cleansing ceremonies to official amnesty processes. Additionally, each participant self-reported their engagement in each type of reintegration program and this questionnaire did not collect details on their experiences with each program. A 3-level variable was created for each kind of reintegration program (e.g. traditional cleansing ceremony, other reintegration program, no reintegration program). Using one-way ANOVA, no variance was found in the APAI score with the alternative categorizations, justifying the decision to collapse all four programs into one variable. Additionally, when comparing those who accessed reintegration programs to those who reintegrated without programming, it is possible that young women might have “self-selected” into these categories,   100 in that those with intact social support systems and a welcoming family/community may have been able to successfully reintegrate without formal programming. Those with limited family and community support and connections may have needed to be served by an interim care center in order to find a safe and sustainable placement following the conflict. Finally, the association between accessing reintegration programming and mental health is measured cross-sectionally. This analysis did not measure the mental health status of abductees prior to their abduction or after their abduction, nor can the relationship between reintegration and mental health be causally inferred based on this analysis.  4.6 Conclusion The young women in this study were abducted into the LRA at a young age, spent an average of one year in captivity, and only half were able to access a reintegration process upon return. This finding highlights the need to generate more and better opportunities for young women who are reintegrating to live “normal” lives, become a functional member of society, resume education, gain skills training, and reduce trauma including anxiety and depression.    101 Chapter 5: Discussion, recommendations, and conclusions  5.1 Summary of study findings The health and safety of sex workers living in environments affected by conflict has been an unexplored area. This dissertation describes the prevalence and correlates of experiences of violence, HIV/STI, and access to services among women currently involved in sex work in northern Uganda. It also served to highlight some of the structural conditions (e.g., social stigmatization, mobility, migration, and historical violence) that heighten risk of HIV/STI infection and exposure to violence.  The systematic review presented in Chapter 2 summarized the findings from 20 quantitative studies among sex workers living in Uganda. The majority of the studies were conducted among sex workers living in the urban capital of Kampala and along the trans-Africa highway. The prevalence of HIV infection among sex workers ranged from 32.4-52.0%. Consistent condom use was a constant challenge as between 33.3-55.1% of sex workers reported inconsistent condom use in the previous 30 days. There was only one quantitative study documenting the experiences of violence among sex workers, reporting that 81.1% had experienced at least one form of physical, sexual, verbal or economic violence in the previous six months.  The results from Chapter 3 document that almost 50% of sex workers in the study reported experiencing extreme physical and/or sexual violence from clients, including rape, gang rape, and physical assault in the last six months. Almost half of this sample reported rushing their negotiations with clients because of policing, a finding that was independently associated with   102 increased odds of client violence in the previous six months. This study is among the first quantitative analyses to demonstrate the association between policing and client violence among sex workers in Uganda, where sex workers are persecuted and regularly face arrest. In addition to policing, three other labour-based factors (i.e., place of service, having a pimp/manager, and inconsistent condom use with clients) were found to independently contribute to client violence. Consistent condom use is a key component of HIV prevention and this analysis demonstrates that structural and social factors including client demand for sex without condoms or client violence can inhibit sex workers’ ability to negotiate safer sex work practices. These findings also point to the harms associated with the social norms of male dominance and gender violence that contribute to HIV risk.  The analyses in Chapter 4 found that a third of sex workers in this study had been abducted by the LRA. Less than half of the abductees in this sample had accessed any programmatic form of reintegration, including the formal UN process of disarmament, demobilization, and reintegration (DDR). The female abductees in this study were abducted at the average age of 13, spent an average of one year in captivity, and only half were able to access a reintegration process upon return. As well, half of the women reintegrated without programmatic support while the other half of the sample participated in DDR programming; no significant differences in mental health status were noted between those who accessed a reintegration program and those who did not. The process of reintegration is more complex than what could be seen with the available data; however, the current study contributes to the existing evidence base by documenting the low prevalence of access to reintegration programming, and suggests that   103 carefully planned programming, evaluation, and research will benefit our understanding of the legacy of abduction.  5.2 Study strengths and limitations The criminalized climate of sex work in Uganda presented considerable barriers for government and non-government organizations to access sex worker populations, both for service provision and for research. At the time of this research, many of the study staff had very little experience working with sex workers and offering services free of discrimination. Confidentiality was a key priority of the study protocol. This was particularly important if study staff encountered participants outside of the study office, whether they were soliciting for clients or not. The process of developing a peer-led outreach model and refining and implementing this study in partnership with sex workers provided an opportunity for study staff and TASO staff to learn from sex workers about the challenges they face for health and safety. For example, participants were encouraged to bring their children to the interview and assured that study staff would be available to care for their children during their interview. Through this specific study protocol, the children were assessed for malnutrition and any child deemed to be malnourished was enrolled in a food security program. All participants with children were also connected to programs that serve children, including those that provide childhood vaccinations. Participants regularly asked for services to support school fees for their children, but we were unable to offer this kind of support. The demand for this type of non-sex work related support sheds light on the multiple challenges that sex workers face in providing for their families.     104 The limitations of each analysis are discussed in Chapters 2-4 and an overview of the study limitations is provided below. The study recruitment procedures employed a multi-tier approach to access and enroll sex workers from several different venues. However, the sample of sex workers in this study was not gathered through random sampling and as such, the potential for selection bias is present. Generalizability to a broader population of sex workers may be limited, although peer outreach and sampling at times and locations where sex workers work and/or live is considered a key strategy to increase the representative nature of the sample for this population. The study design relied on the use of a single cross-sectional survey, limiting the ability to infer causality between variables. However, cross-sectional surveys are useful when there is relatively little information known about the outcome within the population. As with many survey designs, all measures are self-reported, introducing the potential for information bias. However, the study interviewers were trained to help participants feel safe when responding to interview questions. All interviews were conducted with a Luo-speaking female research assistant in a safe space of the participants’ choice.   Additionally, research among war-affected populations is only conducted among survivors and the experiences of those who died during the war are not reported. This creates a type of survivor bias that may underestimate the prevalence of the reported findings and limits external generalizability. As mortality estimates are important indicators in emergency settings, the Government of Uganda conducted a mortality survey among IDP camp inhabitants using a method designed to reconstruct the demographic evolution of each household over a specified recall period. Participants listed all members of their household at a specific point in time and then reported whether they were still alive. This method provides information on missing   105 household members. Including this methodology and line of inquiry into studies in settings affected by war with high mortality rates is an important area for future research that can help improve both the precision and reliability of reported estimates.  5.3 Potential implications 5.3.1 Support for the decriminalization of sex work This is one of the first analyses in Uganda to demonstrate the high prevalence of policing (>33%) of female sex workers. The study also demonstrates that policing is associated with increased odds of physical and sexual violence among sex workers in this setting. Given the recent trends to further criminalize sex workers in a number of East and West African countries, including Uganda, the findings of the current study support the need for a global policy response that can hold governments accountable to ensure justice, health and human rights for all, including sex workers. The findings of the current study coincide with and bolster global policy recommendations, including ILO, Global Commission on HIV/AIDS, WHO, and UNAIDS bodies, regarding the need to establish clear evidence-based approaches to ensuring reduced burden of both violence and HIV/STIs among sex workers in Uganda.   It is important to note that Uganda is a country where sex work is severely stigmatized and considered immoral. The Ugandan government has shown no indication that they are willing to work towards protecting the health and safety of sex workers (or sexual minorities). If reducing the burden of HIV among sex workers was to emerge as a public health priority for the Ugandan Government, the results from Chapter 2 that identified the role of police harassment in enabling   106 violence against sex workers could be useful in terms of building a legal foundation and capacity within police and military forces to respect and protect the rights of sex workers.    Unfortunately, many political and legislative barriers remain. For example, in 2014, President Museveni assented to two laws: the Anti-Pornography Act (Parliament of Uganda, 2011), also known as the “Miniskirt Bill,” and the Anti-Homosexuality Act (Parliament of Uganda, 2014), also known as the “Kill the Gays Bill,” both designed to criminalize and persecute sexual minorities including sex workers. Under the anti-pornography bill, pornography is defined as “a) a person engaged in explicit sexual activities or conduct; b) exposing sexual parts of a person such as breasts, thigh, buttocks or genitalia; c) erotic behavior intended to cause sexual excitement; or d) any indecent act or behavior tending to corrupt morals.” The large scope of the anti-pornography bill gives the government broad latitude to harass and arrest women, particularly those identified as sex workers. International policy bodies have spoken out about the extreme dangers of both bills.   Criminalizing of sex work creates substantial barriers for those most in need of health care services and normalizes violence against sex workers (Global Network of Sex Work Projects, 2014b; UNAIDS, 2012; UNDP HIV/AIDS Group, 2012; World Health Organization, UNFPA, UNAIDS, Network of Sex Work Projects, & World Bank, 2013; World Health Organization, 2014). Ugandan civil society organizations have argued that it will not be the international community that advances legislative change in Uganda but rather, “what is needed is a more private, sustained engagement to put pressure on President Museveni to change his mind (PBS Newshour, 2014).” To address the dangers associated with the Anti-Pornography and Anti-  107 Homosexuality Acts, several members of Uganda’s civil society, including the Ugandan sex-worker led Women’s Organization Network for Human Rights Advocacy (WONETHA), Human Rights Network Uganda (HURINET), Legal Aid Service Providers Network of Uganda, Ugandan Human Rights Commission, and the East and Horn of Africa Human Rights Defenders Project, have collaborated to oppose the legislation.    Beyond the illegal status of sex work in many settings, many political and religious leaders, community and health care providers feel that sex work is immoral (Richter et al., 2010). Social discrimination and stigma are common obstacles for sex workers. Legal infrastructure (i.e. decriminalization of sex work) is a key component of changing the social environment for sex workers. Sex workers experience discrimination and stigmatization from clients, families, health service providers and the public. The decriminalization of sex work may not guarantee that others respect sex workers or see sex work as legitimate; however, a sustained and growing dialogue facilitated through protective policies authorized by the government provides a mechanism to support accountability for rights-based programing and services.   5.3.2 Sex work community peer-led outreach Best practices for programming with sex workers includes involving sex workers in all aspects of research and programming. Successful models of care delivery include sex worker/peer-led outreach programs to reach sex workers who may be more hidden and less likely to access services (Kerrigan et al., 2014; World Health Organization et al., 2012). The peer outreach recruitment strategy contributed to the ability to recruit a sample size of 400 sex workers and helped to create an interview environment where sex workers could safely and freely respond to   108 interview questions. This component of community-based research is essential, not only to conduct research, but also to link sex workers to care and ensure their long-term health and safety.   The process of establishing this study also informed the development of a TASO mobile HIV testing program where HIV testing counselors and peer-outreach workers went to several suburbs of Gulu known to be places where sex workers congregate, including Kasubi, Bardege, Kanyagoga, Cerelena, Konypaci, Kasubi, Layibi, Olayoilong, Laliya, and Kanyagoga. This program was designed by the candidate (KM) and the project team to help integrate the lessons learned from establishing this study and the success of reaching sex workers in Gulu.   5.3.3 Interventions for conflict-affected environments Following periods of violent conflict, much of the post-conflict reconstruction focuses on peace building, state and health system strengthening, and restoring the economy, including the informal economy (Rujumba & Kwiringira, 2010). This study has shown that many women living in Gulu, northern Uganda are engaged in sex work and continue to experience a high degree of violence and exposure to HIV/STIs. The AIDS, Security, and Conflict Initiative has cited the need to include support for those engaged in sex work (de Waal, 2010b). However, to date there has been no formal collaboration between conflict management organizations and sex work advocacy groups to integrate sex work into existing guidelines.    Sex trafficking has been documented in many conflicts and features in humanitarian guidelines; yet, there is little documentation of formal sex work in conflict-affected settings. To better   109 formulate human trafficking interventions, the ILO has called for a comprehensive rights-based approach to address the harms of sexual exploitation and collaborate with organizations, including sex work organizations, to help with “early warning” and the identification of trafficking victims (International Labour Organization, 2008). The distinction between sex trafficking and sex work is an ongoing challenge (McClure et al., 2014). The conflation of sex trafficking and sex work inhibits successful interventions to reach sex workers as a key affected population and ensure their health and safety. Persecuting sex workers deviates energy and resources away from those who are trafficked and places it on adults consensually involved in sex work (McClure et al., 2014).  This dissertation also examined the conflict specific experiences of abduction and forced conscription. Within the sample of 400 sex workers, 129 had been abducted by the LRA as children, of which less than half had any form of programmatic reintegration. Within this sample, the most common form of reintegration was the traditional cleansing ceremony. Reintegration is an ongoing component of peace building and transitional justice in Uganda. The findings in Chapter 4 may point to the importance of local ownership over the peace process, in addition to state justice systems and international criminal tribunals.   It has been argued that the war in northern Uganda has never officially ended (Mugisha, Muyinda, Malamba, & Kinyanda, 2015). After the peace agreement was signed between the UPDF and LRA, the peace process was largely led by NGOs and local traditional infrastructure, and was not state sponsored. Amnesty allowed LRA abductees and soldiers to return, receptions centers were established, and traditional cleansing ceremonies were locally led. However, in the   110 absence of financial support and state sponsorship, there were limitations in providing services to all those affected and many abductees did not access any form of reintegration (Annan et al., 2009). Support for local transitional justice mechanisms is an ongoing component of peace building and it is encouraging to see that the traditional cleansing ceremony was one of the most accessed reintegration programs among the women in this sample. Successful examples of the local transitional justice mechanisms took place in Rwanda after the 1994 genocide. Under the government led by President Paul Kagame, the Gacaca court system was conducted, involving locally elected judges that held trials for truth telling and reconciliation. Perpetrators were given the opportunity to confess crimes and ask for forgiveness from the communities. Family and community members were able to learn the truth about the death of their loved ones (Government of Rwanda & United Nations, 2012). By 2012, when the Gacaca system closed, more than 12,000 community-based courts tried more than 1.2 million cases. The post-conflict reconstruction in Rwanda has been one of the most successful examples of the power of local ownership over recovery and reconciliation. One of the key elements of success was the Rwandan State’s endorsement and financial sponsorship of the Gacaca system. The absence of financial and political state support from the Ugandan government has shaped the post-conflict reconstruction and possibly contributed to the low access to reintegration programming (Annan et al., 2007).   5.3.4 Future research Recommendations associated with findings from each chapter are outlined in Chapters 2-4, however, overarching areas for future research will be described here. The findings presented in this dissertation highlight the human rights abuses faced by sex workers and how they continue   111 to be a population faced with high exposure to risk and substantial barriers to care and protective services. Within Uganda, the strategic development of research programs with local stakeholders – including sex work advocacy groups, civil society, academic institutions, and hopefully relevant government bodies including the police force – is a critical foundation for practice-changing research that is sustainable, locally developed, and locally owned. Currently, much of the research among sex workers in Uganda (including this body of work) has been limited to single cities/towns, inhibiting cross-comparison between different populations. The unique experiences with the sex workers in this study who work in northern Uganda documents the high prevalence of physical and sexual violence and associated factors, but cannot assess the specific role that conflict-affected environments play without comparison to an environment not affected by conflict. This could potentially explain the absence of significant associations between conflict-related variables (e.g. living in IDPs or LRA abduction) and the key outcomes of interest.   The topics explored in this dissertation focused on formal commercial sex work in an area affected by conflict and did not explore transactional sex, sex slavery or sex trafficking in great detail. A research agenda that explores the diversity of sex in exchange for resources in conflict-affected settings is an important area for further inquiry. This will require diverse recruitment strategies and research methodologies to identify each population and document their respective practices, risks, and areas for intervention. The history of sex in exchange for resources, both forced and unforced, during times of war, including instances where women and girls have been forcibly trafficked into the military to provide sexual services to soldiers, remains an area for on-going documentation. A historical investigation of the presence of consensual sex work and   112 forced sex trafficking and slavery throughout the course of global wars reflects an important and understudied topic for future work.   5.4 Conclusions Social-structural level factors of criminalization of sex work and the legacy of the civil war in northern Uganda are strong structural determinants that affect the lives of sex workers. The high exposure to sexual and physical violence showcase the need for policies and services designed to protect the health and human rights of sex workers. The added vulnerabilities related to the civil war in Uganda meant that a large proportion of this sample had histories of abduction or displacement. The intersecting risks associated with criminalization and the extreme violence and destabilization following the civil war have left sex workers in need of services and protections. The political and social changes required to address these social determinants are being called for widely. The findings of the current dissertation illustrate that the criminalization of sex work, in tandem with the social instability of conflict, are two social and structural determinants shaping the health and safety of sex workers in northern Uganda. Supporting programming and policies that protect the rights of all sex workers are necessary components for a rights-based approach to ensure that all people can live and work in safe conditions.     113 Bibliography Accorsi, S., Fabiani, M., Nattabi, B., Corrado, B., Iriso, R., Ayella, E. O., … Declich, S. (2005). The disease profile of poverty: morbidity and mortality in northern Uganda in the context of war, population displacement and HIV/AIDS. Transactions of the Royal Society of Tropical Medicine and Hygiene, 99(3), 226–233. Akello, G., Reis, R., & Richters, A. (2010). Silencing distressed children in the context of war in northern Uganda: An analysis of its dynamics and its health consequences. Social Science & Medicine, 71(2), 213–220. Alison, M. (2007). Wartime sexual violence: women’s human rights and questions of masculinity. Review of International Studies, 33(01), 75–90. Allen, T., & Schomerus, M. (2006). A Hard Homecoming: Lessons learned from the reception centre process in northern Uganda. Washington DC. Allen, T., & Vlassenroot, K. (2010). The Lord’s Resistance Army: Myth and reality. (T. Allen & K. Vlassenroot, Eds.). London, UK: Zed Books, 2010. Amon, J. A., Wurth, M., & McLemore, M. (2015). Evaluating Human Rights Advocacy on Criminal Justice and Sex Work. Health and Human Rights Journal, 17, in press. Amowitz, L. L., Reis, C., Lyons, K. H., Vann, B., & Taylor, L. (2002). Prevalence of war-related sexual violence and other human rights abuses among internally displaced persons in Sierra Leone. Journal of the American Medical Association, 287(4), 513–521. Anastario, M. P., Tavarez, M. I., & Chun, H. (2010). Sexual risk behavior among military personnel stationed at border-crossing zones in the Dominican Republic. Pan American Journal of Public Health, 28(5), 361–7. Anderson, C. (2010). (Post) Colonialism, citizenship and domesticity: Intersectionality in feminist histories. Journal of Women’s History, 22(4), 315–325. Annan, J., Blattman, C., Carlson, K., & Mazurana, D. (2007). Making reintegration work for youth in northern Uganda: The Survey of War Affected Youth. Annan, J., Blattman, C., Carlson, K., & Mazurana, D. (2008). The state of female youth in northern Uganda: Findings from the Survey of War-Affected Youth Phase II. Medford, MA. Annan, J., Blattman, C., Mazurana, D., & Carlson, K. (2011). Civil war, reintegration, and gender in northern Uganda. Journal of Conflict Resolution, 55(1), 877–910. Annan, J., Brier, M., & Aryemo, F. (2009). From “Rebel” to “Returnee”: Daily life and reintegration for young soldiers in northern Uganda. Journal of Adolescent Research, 24(6),   114 639–667. Anyeko, K., Baines, E. K., Komakech, E., Ojok, B., Owor Ogora, L., & Victor, L. (2011). “The Cooling of Hearts”: Community truth-telling in northern Uganda. Human Rights Review, 13(1), 107–124. Argento, E., Muldoon, K. A., Duff, P. K., Simo, A., Deering, K. N., & Shannon, K. (2014). High prevalence and partner correlates of physical and sexual violence by intimate partners among steet and off-street sex workers. PloS One, 9(7). Aung, T., Paw, E., Aye, N. M., & McFarland, W. (2014). Coverage of HIV prevention services for female sex workers in seven cities of Myanmar. AIDS and Behavior, 18 Suppl 1, S37–41. Baeten, J. M., Donnell, D., Ndase, P., Mugo, N. R., Campbell, J. D., Wangisi, J., … Celum, C. (2012). Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. The New England Journal of Medicine, 367(5), 399–410. Baleta, A. (2014). Lives on the line: sex work in sub-Saharan Africa. The Lancet, 6736(14). Baral, S. D., Beyrer, C., Muessig, K., Poteat, T., Wirtz, A. L., Decker, M. R., … Kerrigan, D. (2012). Burden of HIV among female sex workers in low-income and middle-income countries: A systematic review and meta-analysis. The Lancet Infectious Diseases, 12(7), 538–49. Baral, S. D., Friedman, M. R., Geibel, S., Rebe, K., Bozhinov, B., Diouf, D., … Cáceres, C. F. (2014). Male sex workers: practices, contexts, and vulnerabilities for HIV acquisition and transmission. The Lancet, 6736(14). Benoit, C., Roth, E., Hallgrimsdottir, H., Jansson, M., Ngugi, E., & Sharpe, K. (2013). Benefits and constraints of intimate partnerships for HIV positive sex workers in Kibera, Kenya. International Journal for Equity in Health, 12(1), 76. http://doi.org/10.1186/1475-9276-12-76 Berkley, S. F., Widy-Wirski, R., Okware, S. I., Downing, R., Linnan, M. J., White, K. E., & Sempala, S. (1989). Risk factors associated with HIV infection in Uganda. Journal of Infectious Diseases, 160(1), 22–30. Berkley-Tulane Initiative on Vulnerable Populations. (2007). Abducted: The Lord’s Resistance Army and forced conscription in northern Uganda. California. Betancourt, T. S. (2008). Building an evidence base on mental health interventions for children affected by armed conflict. Intervention, 6(1), 39–56. Betancourt, T. S., Agnew-Blais, J., Gilman, S. E., Williams, D. R., & Ellis, B. H. (2010). Past   115 horrors, present struggles: The role of stigma in the association between war experiences and psychosocial adjustment among former child soldiers in Sierra Leone. Social Science & Medicine, 70(1), 17–26. Betancourt, T. S., Bass, J., & Borisova, I. (2009). Assessing local instrument reliability and validity: A field-based example from northern Uganda. Social Psychiatry and Psychiatric Epidemiology, 44(8), 685–692. Betancourt, T. S., Borisova, I. I., de la Soudiere, M., & Williamson, J. (2011). Sierre Leone’s child soldiers: War exposure and mental health problems by gender. Journal of Adolescent Health, 49(1), 21–28. Betancourt, T. S., Borisova, I. I., Williams, P., Brennan, R. T., Whitfield, T. H., de la Soudiere, M., … Gilman, S. E. (2010). Sierre Leone’s former child soldiers: A follow-up study of psychosocial adjustment and community reintegration. Child Development, 81(4), 1077–1095. Betancourt, T. S., Borisova, I., Williams, T. P., Meyers-Ohki, S. E., Rubin-Smith, J. E., Annan, J., & Kohrt, B. A. (2012). Research review: Psychosocial adjustment and mental health in former child soldiers - a systematic review of the literature and recommendations for future research. Journal of Child Psychology and Psychiatry, 54(1), 17–36. Betancourt, T. S., Brennan, R. T., Rubin-Smith, J., Fitzmaurice, G. M., & Gilman, S. E. (2010). Sierra Leone’s former child soldiers: a longitudinal study of risk, protective factors, and mental health. Journal of the American Academy of Child and Adolescent Psychiatry, 49(6), 606–15. Betancourt, T. S., Meyers-Ohki, S. E., Charrow, A., & Hansen, N. (2012). Research review: Mental health and resilience in HIV/AIDS-affected children: a review of the literature and recommendations for future research. Journal of Child Psychology and Psychiatry, 54(4), 423–44. Betancourt, T. S., Newnham, E. A., Brennan, R. T., Verdeli, H., Borisova, I., Neugebauer, R., … Bolton, P. (2012). Moderators of treatment effectiveness for war-affected youth with depression in northern Uganda. The Journal of Adolescent Health, 51(6), 544–50. Beyrer, C., Baral, S. D., Kerrigan, D., El-Bassel, N., Bekker, L., & Celentano, D. D. (2011). Expanding the space: Inclusion of Most-at-Risk Populations in HIV prevention, treatment, and care services. Journal of Acquired Immune Deficiency Syndromes, 57(Suppl 2), 1–7. Beyrer, C., Crago, A. L., Bekker, L. G., Butler, J., Shannon, K., Kerrigan, D., … Strathdee, S. A. (2014). An action agenda for HIV and sex workers. The Lancet, 6736(14), 1–14. Biague, A., Månsson, F., da Silva, Z., Dias, F., Nantote, Q., Costa, J., … Norrgren, H. (2010).   116 High sexual risk taking and diverging trends of HIV-1 and HIV-2 in the military of guinea bissau. Journal of Infection in Developing Countries, 4(5), 301–308. Bing, E. G., Ortiz, D. J., Ovalle-Bahamon, R. E., Cheng, K., Huang, F. H., Ernesto, F., & Duan, N. (2010). HIV/AIDS behavioral surveillance among Angolan military men. AIDS & Behavior, 9(2), 1–14. Birkeland, N. M., & Ridderbos, K. (2010). Difficulties continue for returnees and remaining IDPs as development phase begins. Geneva. Blattman, C. (2006). The Survey of War Affected Youth: Research & program for youth in armed conflict in Uganda. Blattman, C., & Annan, J. (2006). The state of youth and youth protection in northern Uganda: Findings from the Survey for War Affected Youth. Blattman, C., & Annan, J. (2010). The consequences of child soldiering. The Review of Economics and Statistics, 92(4), 882–898. Boas, M., & Hatloy, A. (2006). Northern Uganda internally displaced persons profiling study, 1–66. Bolton, P., Bass, J., Betancourt, T. S., Speelman, L., Onyango, G., Clougherty, K. F., … Verdeli, H. (2007). Interventions for depression symptoms among adolescent survivors of war and displacement in northern Uganda: a randomized controlled trial. Journal of the American Medical Association, 298(5), 519–27. Borzello, A. (2007). The challenge of DDR in northern Uganda!: The Lord’s Resistance Army. Conflict, Security & Development, 7(3), 387–415. Bourdieu, P. (2007). Gender and symbolic violence. In N. Scheper-Hughes & P. Bougois (Eds.), Violence in war and peace: An anthology (pp. 339–342). Malden: Blackwell Publishing. Bourdieu, P., & Wacquant, L. (2007). Symbolic violence. In N. Scheper-Hughes & P. Bourgois (Eds.), Violence in war and peace: An anthology (pp. 272–274). Malden: Blackwell Publishing. Bowleg, L. (2012). The problem with the phrase women and minorities: Intersectionality - an important theoretical framework for public health. American Journal of Public Health, 102, 1267–1273. Braun, N., Chakrabarti, O., Forbes, J., Frey, B., Gómez, E., Jiwatram, J., … Nassali, M. (2012). In Pursuit of Justice: Progress of the World’s Women. Bukenya, J., Vandepitte, J., Kwikiriza, M., Weiss, H. A., Hayes, R., & Grosskurth, H. (2013). Condom use among female sex workers in Uganda. AIDS Care, 25(6), 767–74.   117 Chersich, M. F., Bosire, W., King’ola, N., Temmerman, M., & Luchters, S. (2014). Effects of hazardous and harmful alcohol use on HIV incidence and sexual behaviour: a cohort study of Kenyan female sex workers. Globalization and Health, 10(1), 22–33. Chersich, M. F., Luchters, S. M. F., Malonza, I. M., Mwarogo, P., King’ola, N., & Temmerman, M. (2007). Heavy episodic drinking among Kenyan female sex workers is associated with unsafe sex, sexual violence and sexually transmitted infections. International Journal of STD & AIDS, 18(11), 764–9. http://doi.org/10.1258/095646207782212342 Chersich, M. F., Luchters, S., Ntaganira, I., Gerbase, A., Lo, Y.-R. R., Scorgie, F., & Steen, R. (2013). Priority interventions to reduce HIV transmission in sex work settings in sub-Saharan Africa and delivery of these services. Journal of the International AIDS Society, 16(1), 1–8. Coalition to Stop the Use of Child Soldiers. (2008). Child Soldiers: Global Report 2008. Coates, T. J., Richter, L., & Caceres, C. (2008). Behavioural strategies to reduce HIV transmission: how to make them work better. Lancet, 372(9639), 669–84. Cohen, D. K. (2007). Explaining sexual violence during civil war: Evidence from the Sierra Leone War (1991-2002). American Political Science Association. Chicago. Collaborative Institutional Training Initiative. (2014). Good Clinical Practice Training. Retrieved from http://citiprogram.desk.com/customer/portal/articles/775278-good-clinical-practice-gcp-catalog Collins, S. P., Goldenberg, S. M., Burke, N. J., Bojorquez-Chapela, I., Silverman, J. G., & Strathdee, S. A. (2013). Situating HIV risk in the lives of formerly trafficked female sex workers on the Mexico-US border. AIDS Care, 25(4), 459–65. Crago, A. L., & Arnott, J. (2009). Rights not rescue: A report on female, trans, and male sex workers’ human rights in Botswana, Namibia, and South Africa. New York City. Cruz, A., & Klinger, S. (2011). Gender-based violence in the world of work: Overview and selected annotated bibliography. Geneva. De Vries, H., & Wiegink, N. (2011). Breaking up and going home? Contesting two assumptions in the demobilization and reintegration of former combatants. International Peacekeeping, 18(1), 38–51. de Waal, A. (2010a). HIV/AIDS and the challenges of security and conflict. The Lancet, 375(9708), 22–3. de Waal, A. (2010b). Reframing governance, security and conflict in the light of HIV/AIDS: A synthesis of findings from the AIDS, Security and Conflict Initiative. Social Science &   118 Medicine, 70(1), 114–20. de Waal, A., Klot, J. F., Mahajan, M., Huber, D., Frerks, G., M’Boup, S., & Security and Conflict AIDS Initiative. (2010). HIV/AIDS, security and conflict: New realities, new responses. Brooklyn. Decker, M. R. (2013). Sex trafficking, sex work, and violence: Evidence for a new era. International Journal of Gynaecology and Obstetrics, 120(2), 113–4. Decker, M. R., Crago, A. L., Chu, S. K., Sherman, S. G., Seshu, M. S., Buthelezi, K., … Beyrer, C. (2014). Human rights violations against sex workers: Burden and effect on HIV. The Lancet, 6736(14), 1–14. Decker, M. R., Oram, S., Gupta, J., & Silverman, J. G. (2009). Forced prostitution and trafficking for sexual exploitation among women and girls in situations of migration and conflict: Review and recommendations for reproductive health care personnel. Women, Migration, and Conflict, (3), 63–86. Decker, M. R., Pearson, E., Illangasekare, S. L., Clark, E., & Sherman, S. G. (2013). Violence against women in sex work and HIV risk implications differ qualitatively by perpetrator. BMC Public Health, 13(1), 876. Decker, M. R., Wirtz, A. L., Pretorius, C., Sherman, S. G., Sweat, M. D., Baral, S. D., … Kerrigan, D. L. (2013). Estimating the impact of reducing violence against female sex workers on HIV epidemics in Kenya and Ukraine: A policy modeling exercise. American Journal of Reproductive Immunology, 69 Suppl 1, 122–32. Deering, K. N., Amin, A., Shoveller, J., Nesbitt, A., Garcia-Moreno, C., Duff, P., … Shannon, K. (2014). A systematic review of the correlates of violence against sex workers. American Journal of Public Health, 104(5), e42–54. Delany-Moretlwe, S., Bello, B., Kinross, P., Oliff, M., Chersich, M., Kleinschmidt, I., & Rees, H. (2014). HIV Prevalence and risk in long-distance truck drivers in South Africa: a national cross-sectional survey. International Journal of STD & AIDS, 25(6), 428–438. Dhana, A., Luchters, S., Moore, L., Lafort, Y., Roy, A., Scorgie, F., & Chersich, M. (2014). Systematic review of facility-based sexual and reproductive health services for female sex workers in Africa. Globalization and Health, 10(1), 46–75. Diouf, D. (2007). HIV/AIDS policy in Senegal: a civil society perspective. New York. Ditmore, M. H., & Allman, D. (2013). An analysis of the implementation of PEPFAR’s anti-prostitution pledge and its implications for successful HIV prevention among organizations working with sex workers. Journal of the International AIDS Society, 16, 1–13.   119 Djomand, G., Quaye, S., & Sullivan, P. S. (2014). HIV epidemic among key populations in west Africa. Current Opinion in HIV and AIDS, 9(5), 506–513. do Espirito Santo, M. E., & Etheredge, G. D. (2003). HIV prevalence and sexual behaviour of male clients of brothels’ prostitutes in Dakar, Senegal. AIDS Care, 15(1), 53–62. Dolan, C. (2009). Social torture: The case of northern Uganda, 1986-2006. Berghahn Books. Doocy, S., Tappis, H., Haskew, C., Wilkinson, C., & Spiegel, P. (2011). Performance of UNHCR nutrition programs in post-emergency refugee camps. Conflict and Health, 5(1), 23. http://doi.org/10.1186/1752-1505-5-23 El-Bassel, N., Witte, S. S., Wada, T., Gilbert, L., & Wallace, J. (2001). Correlates of partner violence among female street-based sex workers: substance abuse, history of childhood abuse, and HIV risks. AIDS Patient Care and STDs, 15(1), 41–51. Elmore-Meegan, M., Conroy, R. M., & Agala, C. B. (2004). Sex workers in Kenya, numbers of clients and associated risks: An exploratory survey. Reproductive Health Matters, 12(23), 50–7. Farmer, P. (2007). On suffering and structural violence: A view from below. In N. Scheper-Hughes & P. Bougois (Eds.), Violence in War and Peace: An anthology (pp. 281–289). Malden: Blackwell Publishing. Fleming, A. F. (1988). Seroepidemiology of human immunodeficiency viruses in Africa. Biomedicine and Pharmacotherapy, 42, 309–320. Foley, E. E., & Nguer, R. (2010). Courting success in HIV/AIDS prevention: the challenges of addressing a concentrated epidemic in Senegal. African Journal of AIDS Research, 9, 325–336. Gaines, T. L., Rusch, M. L., Brouwer, K. C., Goldenberg, S. M., Lozada, R., Robertson, A. M., … Patterson, T. L. (2013). Venue-level correlates of female sex worker registration status: A multilevel analysis of bars in Tijuana, Mexico. Global Public Health, 8(4), 405–416. Galea, S., & Link, B. G. (2013). Six paths for the future of social epidemiology. American Journal of Epidemiology, 178(6), 843–9. Galea, S., Riddle, M., & Kaplan, G. A. (2010). Causal thinking and complex system approaches in epidemiology. International Journal of Epidemiology, 39(1), 97–106. Galtung, J. (1969). Violence, peace, and peace research. Journal of Peace Research, 6(3), 167–191. Global Network of Sex Work Projects. (2014a). Global briefing paper!: Sex workers’ access to HIV treatment around the world.   120 Global Network of Sex Work Projects. (2014b). Sex worker-led HIV programming global report. Edinburgh. Goldenberg, S. M., Rangel, G., Staines, H., Vera, A., Lozada, R., Nguyen, L., … Strathdee, S. A. (2013). Individual, interpersonal, and social-structural correlates of involuntary sex work among female sex workers in two Mexico-U.S. border cities. Journal of Acquired Immune Deficiency Syndromes, 63(5), 639–646. Gostin, L. O. (2013a). PEPFAR’s antiprostitution “loyalty oath”: Politicizing public health. The Hastings Center Report, 43(3), 11–2. Gostin, L. O. (2013b). PEPFAR’s antiprostitution pledge: Spending power and free speech in tension. Journal of the American Medical Association, 3010(11), 1127–1128. Government of Rwanda, & United Nations. (2012). Background information on the justice and reconciliation process in Rwanda: Outreach programme on the Rwanda genocide and the United Nations. Government of Uganda. Constitution of the Republic of Uganda: Police Act (1994). Uganda. Government of Uganda. (2010). UNGASS country progress report: Uganda. Kampala. Government of Uganda. (2013). HIV and AIDS Uganda Country Progress Report. Grosso, A. L., Ketende, S., Dam, K., Papworth, E., Ouedraogo, H. G., Ky-zerbo, O., & Baral, S. D. (2015). Structural Determinants of Health Among Women Who Started Selling Sex as Minors in Burkina Faso. Journal of Acquired Immune Deficiency Syndrom, 68(S2), 162–170. Gu, J., Bai, Y., Lau, J. T. F., Hao, Y., Cheng, Y., Zhou, R., & Yu, C. (2013). Social Environmental Factors and Condom Use Among Female Injection Drug Users who are Sex Workers in China. AIDS and Behavior, 18(2), 18–91. Guédou, F. A., Van Damme, L., Deese, J., Crucitti, T., Becker, M., Mirembe, F., … Alary, M. (2013). Behavioural and medical predictors of bacterial vaginosis recurrence among female sex workers: longitudinal analysis from a randomized controlled trial. BMC Infectious Diseases, 13, 208–219. Guédou, F. A., Van Damme, L., Mirembe, F., Solomon, S., Becker, M., Deese, J., … Alary, M. (2012). Intermediate vaginal flora is associated with HIV prevalence as strongly as bacterial vaginosis in a cross-sectional study of participants screened for a randomised controlled trial. Sexually Transmitted Infections, 88, 545–551. http://doi.org/10.1136/sextrans-2011-050319 Gysels, M., Pool, R., & Bwanika, K. (2001). Truck drivers, middlemen and commercial sex   121 workers: AIDS and the mediation of sex in south west Uganda. AIDS Care, 13(3), 373–385. Gysels, M., Pool, R., & Nnalusiba, B. (2002). Women who sell sex in a Ugandan trading town: Life histories, survival strategies and risk. Social Science & Medicine, 54(2), 179–92. Hallum-Montes, R., D’Souza, R., Tavarez, M. I., Manzanero, R., Dann, G. E., Chun, H. M., & Anastario, M. P. (2012). Condom use during last sexual contact and last 30 days in two samples of Caribbean military personnel. American Journal of Men’s Health, 6(2), 132–5. Hankivsky, O. (2012). Women’s health, men's health and gender and health: The implications of intersectionality. Social Science and Medicine, 74(11), 1712–1720. Hennis, A. J., Kataaha, P., Lloyd, G., Moore, A. T., Sutehall, G. M., Whetstone, R., … Karpas, A. (1988). Risk factors for the spread of AIDS in rural Africa: evidence from a comparative seroepidemiological survey of AIDS, hepatitis B and syphilis in southwestern Uganda. AIDS, 2, 255–260. Henttonen, M., Watts, C., Roberts, B., Kaducu, F., & Borchert, M. (2008). Health services for survivors of gender-based violence in northern Uganda: A qualitative study. Reproductive Health Matters, 16(31), 122–31. Horn, R. (2009). Coping with displacement: Problems and responses in camps for the internally displaced in Kitgum, northern Uganda. Intervention, 7(2), 110–129. Hubbard, D., & Zimba, E. (2003). Sex work and the law in Namibia: A culture-sensitive approach. Research for Sex Work, 6, 10–11. Human Rights Watch. (2003). Abducted and abused: Renewed conflict in northern Uganda (Vol. 15). Washington DC. Inter-Agency Working Group on DDR. (2006). Integrated Disarmament Demobilization and Reintegration standards. Internal Displacement Monitoring Centre. (2011a). A humanitarian crisis in need of a development solution. Retrieved June 3, 2014, from http://www.internal-displacement.org/americas/haiti/2012/a-humanitarian-crisis-in-need-of-a-development-solution Internal Displacement Monitoring Centre. (2011b). Secure tenure and land access still challenges for long-term IDPs. Retrieved June 3, 2014, from http://www.internal-displacement.org/sub-saharan-africa/burundi/2011/secure-tenure-and-land-access-still-challenges-for-long-term-idps International Labour Organization. (1999). Convention C182 - Worst Forms of Child Labour Convention. Geneva.   122 International Labour Organization. (2008). Action Against Trafficking in Human Beings. Geneva. Jackson, L. A., Augusta-Scott, T., Burwash-Brennan, M., Karabanow, J., Robertson, K., & Sowinski, B. (2009). Intimate relationships and women involved in the sex trade: perceptions and experiences of inclusion and exclusion. Health, 13(1), 25–46. Joireman, S. F., Sawyer, A., & Wilhoit, J. (2012). A different way home: Resettlement patterns in Northern Uganda. Political Geography, in press(4), 197–204. Justice and Reconciliation Project. (2007). Remembering the Atiak Massacre April 20th 1995. Justice and Reconciliation Project. (2012). Gender and Generation in Acholi Traditional Justice Mechanisms. Gulu. Karim, Q. a., Karim, S. S. a, Soldan, K., & Zondi, M. (1995). Reducing the risk of HIV infection among South African sex workers: Socioeconomic and gender barriers. American Journal of Public Health, 85(11), 1521–1525. http://doi.org/10.2105/AJPH.85.11.1521 Karunakara, U. K., Neuner, F., Schauer, M., Singh, K., Hill, K., Elbert, T., & Burnham, G. (2004). Traumatic events and symptoms of post-traumatic stress disorder amongst Sudanese nationals, refugees and Ugandans in the West Nile. African Health Science, 4(2), 83–93. Kelly, J. T., Betancourt, T. S., Mukwege, D., Lipton, R. I., & Vanrooyen, M. J. (2011). Experiences of Female Survivors of Sexual Violence in Eastern Democratic Republic of the Congo: A mixed-methods study. Conflict and Health, 5(1), 25–33. Kerrigan, D., Kennedy, C. E., Morgan-Thomas, R., Reza-Paul, S., Mwangi, P., Win, K. T., … Butler, J. (2014). A community empowerment approach to the HIV response among sex workers: Effectiveness, challenges, and considerations for implementation and scale-up. The Lancet, 6736(14), 1–14. Kerrigan, D., Wirtz, A., Semini, I., N’Jie, N., Stanciole, A., Butler, J., … Beyrer, C. (2013). The global HIV epidemics among sex workers. The World Bank. Keyes, K. M., & Galea, S. (2014). Current practices in teaching introductory epidemiology: How we got here, where to go. American Journal of Epidemiology, 180(7), 661–668. Kiapi, E. (2012). Inside the tough world of sex work. Retrieved December 13, 2012, from http://www.observer.ug/index.php?option=com_content&task=view&id=11398&Itemid=59 Klasen, F., Reissmann, S., Voss, C., & Okello, J. (2014). The Guiltless Guilty: Trauma-Related Guilt and Psychopathology in Former Ugandan Child Soldiers. Child Psychiatry & Human Development, 180–193. Krieger, N. (2001). A glossary for social epidemiology. Journal of Epidemiology and Community Health, 55, 693–700.   123 Lang, D. L., Salazar, L. F., DiClemente, R. J., & Markosyan, K. (2013). Gender based violence as a risk factor for HIV-associated risk behaviors among female sex workers in Armenia. AIDS and Behavior, 17(2), 551–8. Larsen, M. M., Sartie, M.-T., Musa, T., Casey, S. E., Tommy, J., & Saldinger, M. (2004). Changes in HIV/AIDS/STI knowledge, attitudes and practices among commercial sex workers and military forces in Port Loko, Sierra Leone. Disasters, 28(3), 239–54. Laurent, C., Seck, K., Coumba, N., Kane, T., Samb, N., Wade, A., … Delaporte, E. (2003). Prevalence of HIV and other sexually transmitted infections, and risk behaviours in unregistered sex workers in Dakar, Senegal. AIDS, 17(12), 1811–1816. Lazarus, L., Deering, K. N., Nabess, R., Gibson, K., Tyndall, M. W., & Shannon, K. (2011). Occupational stigma as a primary barrier to health care for street-based sex workers in Canada. Culture, Health & Sexuality, 14(2), 139–150. Lees, S., Zalwango, F., Andrew, B., Vandepitte, J., Seeley, J., Hayes, R. J., & Francis, S. C. (2014). Understanding motives for intravaginal practices amongst Tanzanian and Ugandan women at high risk of HIV infection: the embodiment of social and cultural norms and well-being. Social Science & Medicine, 102, 165–173. Lim, S., Peitzmeier, S., Cange, C., Papworth, E., Lebreton, M., Tamoufe, U., … Baral, S. (2015). Violence Against Female Sex Workers in Cameroon: Accounts of Violence, Harm Reduction, and Potential Solutions. Journal of Acquired Immune Deficiency Syndrom, 68(S2), 241–247. Lloyd, J., Papworth, E., Grant, L., Beyrer, C., & Baral, S. D. (2014). Systematic review and meta-analysis of HIV prevalence among men in militaries in low income and middle income countries. Sexually Transmitted Infections, 90(5), 382–7. Lokuge, K., Shah, T., Pintaldi, G., Thurber, K., Martínez-Viciana, C., Cristobal, M., … Banks, E. (2013). Mental health services for children exposed to armed conflict: Médecins Sans Frontières’ experience in the Democratic Republic of Congo, Iraq and the occupied Palestinian territory. Paediatrics and International Child Health, 33(4), 259–72. Luchters, S., Richter, M., Bosire, W., Nelson, G., Kingola, N., Zhang, X. D., … Chersich, M. F. (2013). The contribution of emotional partners to sexual risk taking and violence among female sex workers in Mombasa, Kenya: A cohort study. PLoS ONE, 8(8), 1–10. Magnani, R., Sabin, K., Saidel, T., & Heckathorn, D. (2005). Review of sampling hard-to-reach and hidden populations for HIV surveillance. AIDS, 19(s2), 67–72. Makerere University, Centers for Disease Control and Prevention, & Uganda Ministry of Health. (2009). The Crane Survey Report: High risk group surveys conducted in 2008/9.   124 Marcus, R. (1993). Gender and HIV/AIDS in Subsaharan Africa: the cases of Uganda and Malawi. Bridge development-gender. Brighton. Matovu, J., & Ssebadduka, B. (2012). Sexual risk behaviours, condom use and sexually transmitted infection treatment-seeking behaviours among female sex workers and truck drivers in Uganda. International Journal of STD & AIDS, 23, 267–273. Mbonye, M., Nakamanya, S., Nalukenge, W., King, R., Vandepitte, J., & Seeley, J. (2013). “It is like a tomato stall where someone can pick what he likes”: Structure and practices of female sex work in Kampala, Uganda. BMC Public Health, 13(1), 741–750. Mbonye, M., Nalukenge, W., Nakamanya, S., Nalusiba, B., King, R., Vandepitte, J., & Seeley, J. (2012). Gender inequity in the lives of women involved in sex work in Kampala, Uganda. Journal of the International AIDS Society, 15 Suppl 1, 1–9. Mbonye, M., Rutakumwa, R., Weiss, H., & Seeley, J. (2014). Alcohol consumption and high risk sexual behaviour among female sex workers in Uganda. African Journal of AIDS Research!: AJAR, 13(2), 145–51. McClure, C., Chandler, C., & Bissell, S. (2014). Responses to HIV in sexually exploited children or adolescents who sell sex. The Lancet, 6736(14), 2012–2014. Mckay, S. (2004). Reconstructing fragile lives: Girls’ social reintegration in northern Uganda and Sierra Leone. Gender & Development, 12(3), 19–30. McMullen, J. D., O’Callaghan, P. S., Richards, J. A., Eakin, J. G., & Rafferty, H. (2011). Screening for traumatic exposure and psychological distress among war-affected adolescents in post-conflict northern Uganda. Social Psychiatry and Psychiatric Epidemiology, 47(9), 1489–98. Mercy, J. A., Butchart, A., Rosenberg, M. L., Dahlberg, L., & Harvey, A. (2008). Preventing violence in developing countries: A framework for action. International Journal of Injury Control and Safety Promotion, 15(4), 197–208. Mgbako, C., & Smith, L. A. (2010). Sex work and human rights in Africa. Fordham International Law Journal, 1178(2009), 1–36. Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Academia and Clinic Annals of Internal Medicine Preferred Reporting Items for Systematic Reviews and Meta-Analyses!: Annulas of Internal Medicine, 151(4), 264–269. Mooney, A., Kidanu, A., Bradley, H. M., Kumoji, E. K., Kennedy, C. E., & Kerrigan, D. (2013). Work-related violence and inconsistent condom use with non-paying partners among female sex workers in Adama City, Ethiopia. BMC Public Health, 13(1), 771–781.   125 Moore, L., Chersich, M. F., Steen, R., Reza-Paul, S., Dhana, A., Vuylsteke, B., … Scorgie, F. (2014). Community empowerment and involvement of female sex workers in targeted sexual and reproductive health interventions in Africa: a systematic review. Globalization and Health, 10(1), 47–64. Morris, C. N., & Ferguson, A. G. (2006). Estimation of the sexual transmission of HIV in Kenya and Uganda on the trans-Africa highway: The continuing role for prevention in high risk groups. Sexually Transmitted Infections, 82(5), 368–71. Morris, C. N., Morris, S. R., & Ferguson, A. G. (2009). Sexual behavior of female sex workers and access to condoms in Kenya and Uganda on the Trans-Africa highway. AIDS and Behavior, 13(5), 860–5. Mossman, E. (2007). International approaches to decriminalising or legalising prostitution. New Zealand: Ministry of Justice, (October). Mtetwa, S., Busza, J., Chidiya, S., Mungofa, S., & Cowan, F. (2013). “You are wasting our drugs”: Health service barriers to HIV treatment for sex workers in Zimbabwe. BMC Public Health, 13, 698–705. Muggah, R. (2005). No magic bullet: A critical perspective on Disarmament, Demobilization and Reintegration (DDR) and weapons reduction in post-conflict contexts. The Round Table, 94(379), 239–252. Mugisha, J., Muyinda, H., Malamba, S., & Kinyanda, E. (2015). Major depressive disorder seven years after the conflict in northern Uganda: burden, risk factors and impact on outcomes (The Wayo-Nero Study). BMC Psychiatry, 15(1), 1–13. Muhwezi, W. W., Kinyanda, E., Mungherera, M., Onyango, P., Ngabirano, E., Muron, J., … Kajungu, R. (2011). Vulnerability to high risk sexual behaviour (HRSB) following exposure to war trauma as seen in post-conflict communities in eastern uganda: A qualitative study. Conflict and Health, 5(1), 22. Muldoon, K. A., Akello, M., Muzaaya, G., Simo, A., & Shannon, K. (2012). Oral Presentation: Alarming Rates of Occupational Violence and Associated HIV Risks Among Young Female Sex Workers in Post-Conflict Northern Uganda. In International AIDS Conference. Washington DC. Muldoon, K. A., Deering, K. N., Feng, C. X., Shoveller, J. A., & Shannon, K. (2014). Sexual relationship power and intimate partner violence among sex workers with non-commercial intimate partners in a Canadian setting. AIDS Care, 27(4), 512–519. http://doi.org/10.1080/09540121.2014.978732 Muldoon, K. A., Muzaaya, G., Betancourt, T. S., Ajok, M., Akello, M., Petruf, Z., … Shannon,   126 K. (2014). After abduction: Exploring access to reintegration programs and mental health status among young female abductees in northern Uganda. Conflict and Health, 8(5), 1–9. Mulumba, D. (2011). Encampment of communities in war-affected areas and its effect on their livelihood security and reproductive health: The case of northern Uganda. East Africa Social Science Research Review, 27, 107–131. Nathan, N., Tatay, M., Piola, P., Lake, S., Brown, V., Tassy, S., … Gorincour, G. (2004). High mortality in displaced populations of northern Uganda. The Lancet, 363, 5736. National Institute for Health Research. (2015). PROSPERO: International prospective register of systematic reviews. Retrieved March 24, 2015, from http://www.crd.york.ac.uk/PROSPERO/ National Institute of Health. (2014). Protecting Human Research Participants: Online Course. Ngugi, E., Benoit, C., Hallgrimsdottir, H., Jansson, M., & Roth, E. A. (2012a). Family Kinship Patterns and Female Sex Work in the Informal Urban Settlement of Kibera, Nairobi, Kenya. Human Ecology, 40(3), 397–403. http://doi.org/10.1007/s10745-012-9478-3 Ngugi, E., Benoit, C., Hallgrimsdottir, H., Jansson, M., & Roth, E. A. (2012b). Partners and clients of female sex workers in an informal urban settlement in Nairobi, Kenya. Culture, Health & Sexuality, 14(1), 17–30. http://doi.org/10.1080/13691058.2011.608436 Ngugi, E., Roth, E., Mastin, T., Nderitu, M. G., & Yasmin, S. (2012). Female sex workers in Africa: epidemiology overview, data gaps, ways forward. Journal of Social Aspects of HIV/AIDS Research Alliance, 9(3), 148–53. Ntozi, J. P. M., Mulindwa, I. N., Ahimbisibwe, F., Ayiga, N., Odwee, J., Najjumba, I. M., … Odwee, J. (2003). Has the HIV/AIDS epidemic changed sexual behaviour of high risk groups in Uganda? African Health Sciences, 3, 107–116. Ntumbanzondo, M., Dubrow, R., Niccolai, L. M., Mwandagalirwa, K., & Merson, M. H. (2006). Unprotected intercourse for extra money among commercial sex workers in Kinshasa, Democratic Republic of Congo. AIDS Care, 18(7), 777–85. Nyakairu, F. (2008). Uganda: Joseph Kony’s killing fields in northern region. Retrieved July 17, 2013, from http://www.ligi.ubc.ca/?p2=/modules/liu/news/view.jsp&id=323 Nyanzi, S. (2013). Homosexuality, Sex Work, and HIV/AIDS in Displacement and Post-Conflict Settings: The Case of Refugees in Uganda. International Peacekeeping, 20, 450–468. Oakes, J. M., & Kaufman, J. S. (2006). Methods in social epidemiology. (J. . Oakes & J. . Kaufman, Eds.) (First Edit). San Francisco: Jossey-Bass Books. Ochen, E. A. (2015). Children and young mothers’ agency in the context of conflict: A review of   127 the experiences of formerly abducted young people in Northern Uganda. Child Abuse & Neglect, 1–12. Okal, J., Chersich, M. F., Tsui, S., Sutherland, E., Temmerman, M., & Luchters, S. (2011). Sexual and physical violence against female sex workers in Kenya: a qualitative enquiry. AIDS Care, 23(March 2015), 612–618. Oosterhoff, P., Mills, E., & Oosterom, M. (2014). Addressing sexual violence in and beyond the “warzone.” Rapid Response, (07), 1–4. Open Society Foundation. (2015). 10 reasons to decriminalize sex work. New York. Panchanadeswaran, S., Johnson, S. C., Sivaram, S., Srikrishnan, A. K., Latkin, C., Bentley, M. E., … Celentano, D. (2008). Intimate partner violence is as important as client violence in increasing street-based female sex workers’ vulnerability to HIV in India. The International Journal on Drug Policy, 19(2), 106–12. Papworth, E., Ceesay, N., An, L., Thiam-Niangoin, M., Ky-Zerbo, O., Holland, C., … Baral, S. D. (2013). Epidemiology of HIV among female sex workers, their clients, men who have sex with men and people who inject drugs in West and Central Africa. Journal of the International AIDS Society, 16 Suppl 3(Suppl 3), 1–11. Parker, R., & Aggleton, P. (2003). HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action. Social Science & Medicine, 57(1), 13–24. Parliament of Uganda. (2011). Anti-Pornography Bill, 2011. Parliament of Uganda. (2014). The Anti-Homosexuality Act, 2014. Patel, S., Schechter, M. T., Sewankambo, N. K., Atim, S., Lakor, S., Kiwanuka, N., & Spittal, P. M. (2014). War and HIV: Sex and gender differences in risk behaviour among young men and women in post-conflict Gulu District, Northern Uganda. Global Public Health, 9, 325–341. Patel, S., Schechter, M. T., Sewankambo, N. K., Atim, S., Oboya, C., Kiwanuka, N., & Spittal, P. M. (2013). Comparison of HIV-related vulnerabilities between former child soldiers and children never abducted by the LRA in northern Uganda. Conflict and Health, 7(1), 17–32. PBS Newshour. (2014). Uganda’s gay rights and sex worker activists answer your questions about HIV prevention. Retrieved October 14, 2014, from http://www.pbs.org/newshour/updates/ugandas-gay-rights-sex-worker-activists-answer-questions-hiv-prevention/ PEPFAR Watch. (2011). Anti-Prostitution Pledge. Retrieved September 13, 2014, from   128 http://www.pepfarwatch.org/the_issues/anti_prostitution_pledge/ Peterson, V. S. (2007). Thinking through intersectionality and war. Race, Gender & Class, 14(3), 10–27. Pham, P. N., Vinck, P., & Stover, E. (2009). Returning home: Forced conscription, reintegration, and mental health status of former abductees of the Lord’s Resistance Army in northern Uganda. BMC Psychiatry, 14, 1–14. Pham, P. N., Vinck, P., & Weinstein, H. M. (2010). Human rights, transitional justice, public health and social reconstruction. Social Science and Medicine, 70(1), 98–105. Pickering, H., Okongo, M., Bwanika, K., Nnalusiba, B., & Whitworth, J. (1997). Sexual behaviour in a fishing community on Lake Victoria, Uganda. Health Transition Review!: The Cultural, Social, and Behavioural Determinants of Health, 7(1), 13–20. Pickering, H., Okongo, M., Nnalusiba, B., Bwanika, K., & Whitworth, J. (1997). Sexual networks in Uganda: Casual and commercial sex in a trading town. AIDS Care, 9(2), 199–207. Pickering, H., Okongo, M., Ojwiya, A., Yirrell, D., & Whitworth, J. (1997). Sexual networks in Uganda: Mixing patterns between a trading town, its rural hinterland and a nearby fishing village. International Journal of STD & AIDS, 8(8), 495–500. Pisani, E., & Caraël, M. (1999). Acting early to prevent AIDS: The case of Senegal. UNAIDS Best Practice Collection (Vol. 99.34E). Pitpitan, E. V, Kalichman, S. C., Eaton, L. A., Strathdee, S. A., & Patterson, T. L. (2013). HIV/STI risk among venue-based female sex workers across the globe: A look back and the way forward. Current HIV/AIDS Reports, 10(1), 65–78. Popoola, B. I. (2013). Occupational hazards and coping strategies of sex workers in southwestern Nigeria. Health Care for Women International, 34(2), 139–49. Poteat, T., Wirtz, A. L., Radix, A., Borquez, A., Silva-Santisteban, A., Deutsch, M. B., … Operario, D. (2014). HIV risk and preventive interventions in transgender women sex workers. The Lancet, 6736(14), 1–13. procon.org. (2009). 100 Countries and Their Prostitution Policies. Retrieved December 13, 2012, from http://prostitution.procon.org/view.resource.php?resourceID=000772 Puechguirbal, N. (2008). Gender Training for Peacekeepers!: Lessons from the DRC. International Peacekeeping, 10(4), 113–128. Redd, A. D., Ssemwanga, D., Vandepitte, J., Wendel, S. K., Ndembi, N., Bukenya, J., … Kaleebu, P. (2014). Rates of HIV-1 superinfection and primary HIV-1 infection are similar   129 in female sex workers in Uganda. AIDS, 28, 2147–2152. Republic of Uganda. (2012). Child soldiers: Uganda country profile. Kampala. Richter, M., Chersich, M. F., Scorgie, F., Luchters, S., Temmerman, M., & Steen, R. (2010). Sex work and the 2010 FIFA World Cup: time for public health imperatives to prevail. Globalization and Health, 6(1), 1–6. Richter, M., Chersich, M. F., Vearey, J., Sartorius, B., Temmerman, M., & Luchters, S. (2014). Migration Status, Work Conditions and Health Utilization of Female Sex Workers in Three South African Cities. Journal of Immigrant & Minority Health, 16, 7–17. Richter, M., Scorgie, F., Chersich, M. F., & Luchters, S. (2014). “There are a lot of new people in town: but they are here for soccer, not for business” a qualitative inquiry into the impact of the 2010 soccer world cup on sex work in South Africa. Globalization and Health, 10(1), 45–56. Rimoin, A. W., Hoff, N. A., Djoko, C. F., Kisalu, N. K., Kashamuka, M., Tamoufe, U., … Wolfe, N. D. (2015). HIV infection and risk factors among the armed forces personnel stationed in Kinshasa, Democratic Republic of Congo. International Journal of STD & AIDS, 26(3), 187–95. Ross, M. W., Crisp, B. R., Månsson, S.-A., & Hawkes, S. (2012). Occupational health and safety among commercial sex workers. Scandinavian Journal of Work, Environment & Health, 38(2), 105–19. Rujumba, J., & Kwiringira, J. (2010). Interface of culture, insecurity and HIV and AIDS: Lessons from displaced communities in Pader District, Northern Uganda. Conflict and Health, 4(1), 18–28. Saile, R., Ertl, V., Neuner, F., & Catani, C. (2014). Does war contribute to family violence against children? Findings from a two-generational multi-informant study in Northern Uganda. Child Abuse & Neglect, 38(1), 135–46. Saiz, I., & Yamin, A. E. (2013). Human rights and social justice: The in(di)visible link. Retrieved from https://www.opendemocracy.net/openglobalrights/ignacio-saiz-alicia-ely-yamin/human-rights-and-social-justice-indivisible-link Scheibe, A., Drame, F. M., & Shannon, K. (2012). HIV prevention among female sex workers in Africa. Journal of Social Aspects of HIV/AIDS Research Alliance, 9(3), 167–72. Schoemaker, J., & Twikirize, J. (2012). A life of fear: Sex workers and the threat of HIV in Uganda. International Journal of Social Welfare, 21, 186–193. Schwitters, A., Swaminathan, M., Serwadda, D., Muyonga, M., Shiraishi, R. W., Benech, I., …   130 Hladik, W. (2015). Prevalence of Rape and Client-Initiated Gender-Based Violence Among Female Sex Workers: Kampala, Uganda, 2012. AIDS and Behavior, 19(S1), 68–76. Scorgie, F., Chersich, M. F., Ntaganira, I., Gerbase, A., Lule, F., & Lo, Y.-R. (2011). Socio-demographic characteristics and behavioral risk factors of female sex workers in sub-saharan Africa: a systematic review. AIDS and Behavior, 16(4), 920–33. Scorgie, F., Nakato, D., Harper, E., Richter, M., Maseko, S., Nare, P., … Chersich, M. F. (2013). “We are despised in the hospitals”: Sex workers’ experiences of accessing health care in four African countries. Culture, Health & Sexuality, 15(4), 450–65. Scorgie, F., Vasey, K., Harper, E., Richter, M., Nare, P., Maseko, S., & Chersich, M. F. (2013). Human rights abuses and collective resilience among sex workers in four African countries: A qualitative study. Globalization and Health, 9(1), 33–46. Sex Workers Education & Advocacy Taskforce. (2012). Decriminalization of sex work: The only legal arrangment which offers dignity to women. Cape Town. Shahmanesh, M., Patel, V., Mabey, D. C., & Cowan, F. M. (2008). Effectiveness of interventions for the prevention of HIV and other sexually transmitted infections in female sex workers in resource poor setting: a systematic review. Tropical Medicine and International Health, 13(5), 659–679. Shannon, K., & Csete, J. (2010). Violence, condom negotiation, and HIV/STI risk among sex workers. Journal of the American Medical Association, 304(5), 573–574. Shannon, K., Strathdee, S. A., Goldenberg, S. M., Duff, P. K., Mwangi, P., Rusakova, M., … Boily, M. C. (2014). Global epidemiology of HIV among female sex workers: Influence of structural determinants. The Lancet, 6736(14), 1–17. Siegfried, N., Van Der Merwe, L., Brocklehurst, P., & Sint, T. T. (2011). Antiretrovirals for reducing the risk of mother-to-child transmission of HIV infection ( Review ). The Cochrane Collaboration, (7), 1–12. Silberman, L. (2000). Hague Child Abduction Convention Turns Twenty: Gender politics and other issues. New York University Journal of International Law and Politics, 33. Simic, O. (2009). Rethinking “sexual exploitation” in UN peacekeeping operations. Women’s Studies International Forum, 32(4), 288–295. Smolak, A. (2013). A meta-analysis and systematic review of HIV risk behavior among fishermen. AIDS Care, 00(00), 1–10. Spiegel, P., & Harroff-Tavel, H. (2006). HIV/AIDS and Internally Displaced Persons in 8 priority countries.   131 Ssemwanga, D., Ndembi, N., Lyagoba, F., Bukenya, J., Seeley, J., Vandepitte, J., … Kaleebu, P. (2012). HIV Type 1 subtype distribution, multiple infections, sexual networks, and partnership histories in female sex workers in Kampala, Uganda. AIDS Research and Human Retroviruses, 28(4), 357–365. Ssemwanga, D., Ndembi, N., Lyagoba, F., Magambo, B., Kapaata, A., Bukenya, J., … Kaleebu, P. (2012). Transmitted antiretroviral drug resistance among drug-naive female sex workers With recent infection in Kampala, Uganda. Clinical Infectious Diseases, 54, S339–S342. Stark, L., Roberts, L., Wheaton, W., Acham, A., Boothby, N., & Ager, A. (2010). Measuring violence against women amidst war and displacement in northern Uganda using the “neighbourhood method.” Journal of Epidemiology and Community Health, 64(12), 1056–61. Steen, R., Jana, S., Reza-Paul, S., & Richter, M. (2014). Trafficking, sex work, and HIV: Efforts to resolve conflicts. The Lancet, 6736(14), 14–16. Stoltenborgh, M., Bakermans-Kranenburg, M. J., & van Ijzendoorn, M. H. (2013). The neglect of child neglect: A meta-analytic review of the prevalence of neglect. Social Psychiatry and Psychiatric Epidemiology, 48(3), 345–55. Supreme Court of the United States. (2013). Agency for International Development et al. v. Alliance for Open Society International, INC., et al. Washington DC. Thobani, S. (2005). Feminism without Borders: Decolonizing Theory, Practicing Solidarity (review). Hypatia, 20(3), 221–224. http://doi.org/10.1177/0891243204264818 Todd, C. S., Nasir, A., Mansoor, G. F., Sahibzada, S. M., Jagodzinski, L. L., Salimi, F., … Scott, P. T. (2012). Cross-sectional assessment of prevalence and correlates of blood-borne and sexually-transmitted infections among Afghan National Army recruits. BMC Infectious Diseases, 12, 196. Todd, C. S., Nasir, A., Stanekzai, M. R., Bautista, C. T., Botros, B. A., Scott, P. T., … Tjaden, J. (2010). HIV, hepatitis B, and hepatitis C prevalence and associated risk behaviors among female sex workers in three Afghan cities. AIDS, 24 Suppl 2, S69–75. Todd, C. S., Nasir, A., Stanekzai, M. R., Scott, P. T., Close, N. C., Botros, B. A., … Tjaden, J. (2011). HIV awareness and condom use among female sex workers in Afghanistan: Implications for intervention. AIDS Care, 23(3), 348–56. Tounkara, F. K., Diabaté, S., Guédou, F. A., Ahoussinou, C., Kintin, F., Zannou, D. M., … Alary, M. (2014). Violence, Condom Breakage, and HIV Infection Among Female Sex Workers in Benin, West Africa. Sexually Transmitted Diseases, 41(5), 312–318. Tumushabe, J. (2006). The politics of HIV/AIDS in Uganda. Social Policy. Geneva.   132 Uganda AIDS Commission. (2012). The Republic of Uganda global AIDS response progress report. Kampala. Uganda Ministry of Health. (2003). Sexually transmitted infections treatment guidelines for use by operational level health workers in Uganda. Kampala. Ulibarri, M. D., Strathdee, S. A., Lozada, R., Magis-Rodriguez, C., Amaro, H., O’Campo, P., & Patterson, T. L. (2010). Intimate Partner Violence among Female Sex Workers in Two Mexico-U.S. Border Cities: Partner Characteristics and HIV Risk-behaviors as Correlates of Abuse. Psychological Trauma!: Theory, Research, Practice and Policy, 2(4), 318–325. http://doi.org/10.1037/a0017500 UNAIDS. (2012). UNAIDS guidance note on HIV and sex work. Geneva. UNDDR. (2012). UN Disarmament Demobilization and Reintegration. Retrieved from www.unddr.org UNDP HIV/AIDS Group. (2012). Global commission on HIV and the law: Risks, rights & health. New York City. UNHCR. (2011). Populations of concern to UNHCR. Geneva. UNHCR. (2013). Global Report 2012: Finding durable solutions. UNICEF. (2014a). Hidden in plain sight: A statistical analysis of violence against children (Vol. 4). New York. UNICEF. (2014b). Unaccompanied children: Impact of armed conflict on children. New York. UNICEF, UNHCR, Save the Children, & World Vision. (2012). A better way to protect all children: The theory and practice of child protection systems. New Delhi. United Nations. (1948). Universal Declaration of Human Rights. Geneva. United Nations. (1990). The Convention on the Rights of the Child. United Nations. (2004). United Nations Convention Against Transnational Organized Crime and Protocols Thereto. Geneva. United Nations. (2006). In-depth study on all forms of violence against women. Geneva. United Nations Department of Economic and Social Affairs. (2014). World economic situation and prospects: Monthly briefing. United Nations Department of Peacekeeping Operations. (2010). Second generation disarmament, demobilization and reintegration (DDR) practices in peace operations. New York City.   133 Urada, L. A., Morisky, D. E., Hernandez, L. I., & Strathdee, S. A. (2013). Social and structural factors associated with consistent condom use among female entertainment workers trading sex in the Philippines. AIDS and Behavior, 17(2), 523–35. Valadez, J. J., Berendes, S., Jeffery, C., Thomson, J., Ben Othman, H., Danon, L., … Mirzoyan, L. (2013). Filling the Knowledge Gap: Measuring HIV Prevalence and Risk Factors among Men Who Have Sex with Men and Female Sex Workers in Tripoli, Libya. PLoS ONE, 8(6), 1–14. Van Damme, L., Govinden, R., Mirembe, F. M., Guédou, F., Solomon, S., Becker, M. L., … Taylor, D. (2008). Lack of effectiveness of cellulose sulfate gel for the prevention of vaginal HIV transmission. The New England Journal of Medicine, 359(5), 463–472. Vandepitte, J. M., Bukenya, J., Hughes, P., Muller, E., Buvé, A., Hayes, R., … Grosskurth, H. (2012). Clinical characteristics associated with Mycoplasma genitalium infection among women at high risk of HIV and other STI in Uganda. Sexually Transmitted Diseases, 39(6), 487–491. Vandepitte, J. M., Bukenya, J., Weiss, H. A., Nakubulwa, S., Francis, S. C., Hughes, P., … Grosskurth, H. (2011). HIV and other sexually transmitted infections in a cohort of women involved in high risk sexual behaviour in Kampala, Uganda. Sexually Transmitted Diseases, 38(4), 316–323. Vandepitte, J. M., Hughes, P., Matovu, G., Bukenya, J., Grosskurth, H., & Lewis, D. A. (2014). High prevalence of ciprofloxacin-resistant gonorrhea among female sex workers in Kampala, Uganda (2008-2009). Sexually Transmitted Diseases, 41(4), 233–237. Vandepitte, J. M., Muller, E., Bukenya, J., Nakubulwa, S., Kyakuwa, N., Buve, A., … Grosskurth, H. (2012). Prevalence and correlates of Mycoplasma genitalium infection among female sex workers in Kampala, Uganda. Journal of Infectious Diseases, 205, 289–296. Vandepitte, J. M., Weiss, H. A., Bukenya, J., Kyakuwa, N., Muller, E., Buve, A., … Grosskurth, H. (2014). Association between Mycoplasma genitalium infection and HIV acquisition among female sex workers in Uganda: evidence from a nested case-control study. Sexually Transmitted Infections, 90, 545–549. Vandepitte, J. M., Weiss, H. A., Kyakuwa, N., Nakubulwa, S., Muller, E., Buve, A., … Grosskurth, H. (2013). Natural history of Mycoplasma genitalium infection in a cohort of female sex workers in Kampala, Uganda. Sexually Transmitted Diseases, 40(5), 422–427. Verdeli, H., Clougherty, K., Onyango, G., Lewandowski, E., Speelman, L., Betancourt, T. S., … Bolton, P. (2008). Group interpersonal psychotherapy for depressed youth in IDP camps in   134 northern Uganda: Adaptation and training. Child and Adolescent Psychiatric Clinics of North America, 17(3), 605–624. Villaran, M. V, Bayer, A., Konda, K. A., Mendoza, C., Quijandria, H., Ampuero, J. S., … Montano, S. M. (2009). Condom use by partner type among military and police personnel in Peru. American Journal of Men’s Health, 58(2), 266–272. Vindevogel, S., Ager, A., Schiltz, J., Broekaert, E., & Derluyn, I. (2015). Toward a culturally sensitive conceptualization of resilience: Participatory research with war-affected communities in northern Uganda. Transcultural Psychiatry, 53(3), 396–416. Vindevogel, S., Coppens, K., Derluyn, I., De Schryver, M., Loots, G., & Broekaert, E. (2011). Forced conscription of children during armed conflict: Experiences of former child soldiers in northern Uganda. Child Abuse & Neglect, 35(7), 551–562. Vindevogel, S., De Schryver, M., Broekaert, E., & Derluyn, I. (2013). Challenges faced by former child soldiers in the aftermath of war in Uganda. Journal of Adolescent Health, 52(6), 757–764. Vindevogel, S., Wessells, M., De Schryver, M., Broekaert, E., & Derluyn, I. (2012). Informal and formal supports for former child soldiers in northern Uganda. The Scientific World Journal, 2012, 1–10. Wang, B., Li, X., McGuire, J., Kamali, V., Fang, X., & Stanton, B. (2009). Understanding the dynamics of condom use among female sex workers in China. Sexually Transmitted Diseases, 36(3), 134–40. Wang, C., Hawes, S. E., Gaye, A., Sow, P. S., Ndoye, I., Manhart, L. E., … Kiviat, N. B. (2007). HIV prevalence, previous HIV testing, and condom use with clients and regular partners among Senegalese commercial sex workers. Sexually Transmitted Infections, 83(7), 534–40. Wechsberg, W. M., Luseno, W. K., & Lam, W. K. (2005). Violence against substance-abusing South African sex workers: intersection with culture and HIV risk. AIDS Care, 17 Suppl 1(November 2013), S55–64. Westerhaus, M. J. (2007). Linking anthropological analysis and epidemiological evidence!: Formulating a narrative of HIV transmission in Acholiland of northern Uganda. Journal of Social Aspects of HIV/AIDS, 4(2), 590–605. Westerhaus, M. J., Finnegan, A. C., Zabulon, Y., & Mukherjee, J. S. (2008). Northern Uganda and paradigms of HIV prevention: The need for social analysis. Global Public Health, 3(1), 39–46. Whiteside, A., de Waal, A., Gebre-Tensae, T., & Whiteside, S. (2006). AIDS, security and the   135 military in Africa: A sober appraisal. African Affairs, 105(419), 201–218. Wirtz, A. L., Schwartz, S., Ketende, S., Anato, S., Nadedjo, F. D., Ouedraogo, H. G., … Baral, S. (2015). Sexual Violence , Condom Negotiation , and Condom Use in the Context of Sex Work!: Results From Two West African Countries. Journal of Acquired Immune Deficiency Syndrom, 68(S2), 171–179. World AIDS Campaign. (2010). Sex work and the law: The case for decriminalization. World Health Organization. (2014). Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. Geneva. World Health Organization, UNFPA, UNAIDS, & Global Network of Sex Work Projects. (2012). Prevention and treatment of HIV and Other sexually transmitted infections for sex workers in Low- and Middle-Income Countries: Recommendations for a public health approach. World Health Organization, UNFPA, UNAIDS, Network of Sex Work Projects, & World Bank. (2013). Implementing comprehensive HIV/STI programmes with sex workers. Geneva. Zalwango, F., Eriksson, L., Seeley, J., Vandepitte, J., & Grosskurth, H. (2010). Parenting and Money Making: Sex Work and Women’s Choices in Urban Uganda. Wagadu, 8(Demystifying Sex Work and Sex Workers), 71–92.    136 Appendices Appendix A  : Search strategy and results summary Database and platform Search date # retrieved Cochrane Library via Wiley (Issue 3 of 12, 2015) Mar 10, 2015 34 Campbell Collaboration Library of Reviews via web Mar 10, 2015 0 MEDLINE and PreMEDLINE  via OVID Mar 10, 2015 108 PSYCINFO via OVID Mar 10, 2015 22 Sociological Abstracts via Proquest Mar 10, 2015 55 Dissertations and Theses via Proquest Mar 11, 2015 47 IDEAS Economics and Finance Research via web Mar 10, 2015 3 BLDS British Library for Development Studies via web Mar 10, 2015 10 ProQuest Dissertations & Theses Global via Proquest Mar 11, 2015 47 ISI-Web of Knowledge via Thompson Mar 11, 2015 118 EconLit  via Proquest Mar 11, 2015 2 Health Evidence via web Mar 11, 2015 7 CAB Abstracts & Global Health via CAB Direct Mar 11, 2015 31 Total 484 Total screened after duplicates removed 351 ! Ovid MEDLINE – Draft search strategy Database: Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) <1946 to Present> Search Strategy: -------------------------------------------------------------------------------- 1     exp Sex Workers/ (770) 2     prostitut*.ti,ab. (3418) 3     exp Prostitution/ (5223) 4     (sex adj3 industry).ti,ab. (261) 5     (sex adj3 tour*).ti,ab. (71) 6     brothel*.ti,ab. (376) 7     (anti adj3 prostitut*).ti,ab. (30) 8     escort.ti,ab. (599) 9     (sex adj3 buy*).ti,ab. (59) 10     (commercial adj3 sex*).ti,ab. (1619) 11     or/1-10 (9077) 12     exp Uganda/ (7605) 13     (northern adj province).ti,ab. (209)   137 14     (West adj Nile adj Province).ti,ab. (4) 15     (West adj Nile adj District).ti,ab. (41) 16     (West adj Nile adj sub-region).ti,ab. (1) 17     (Kampala or Kira or Mbarara or Mukono or Gulu or Nansana or Masaka or Kasese or Hoima or Lira or Mbale or Masindi or Njeru or Jinja or Entebbe or Arua or Wakiso or Busia or Iganga or Mpondwe or Kabale or Soroti or Mityana or Mubende).ti,ab. (2025) 18     Uganda.ti,ab. (8110) 19     or/12-18 (10634) 20     11 and 19 (108)  Cochrane Library 2015 Issue 3 Search Name: Ugandan sex workers Last Saved: 09/03/2015 20:19:00.344  ID Search  #1 MeSH descriptor: [Sex Workers] explode all trees #2 prostitut*  #3 MeSH descriptor: [Prostitution] explode all trees #4 sex near/3 industry  #5 sex near/5 tourism  #6 brothel  #7 anti near/3 prostitution  #8 escort  #9 sex near/3 buyer  #10 commercial sex  #11 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10  #12 Uganda  #13 northern near province  #14 Kampala or Kira or Mbarara or Mukono or Gulu or Nansana or Masaka or Kasese or Hoima or Lira or Mbale or Masindi or Njeru or Jinja or Entebbe or Arua or Wakiso or Busia or Iganga or Mpondwe or Kabale or Soroti or Mityana or Mubende  #15 #12 or #13 or #14  #16 #11 and #15  - 33 items   Campbell Collaboration library –  Volume 0 (2004) - Volume 11 (2015) http://www.campbellcollaboration.org/lib/?go=browse_issues  Search strategy: hand searched, browsed all issues  Database: PsycINFO <1806 to March Week 1 2015> Search Strategy: -------------------------------------------------------------------------------- 1     Prostitution/ (2562) 2     (sex adj2 work*).ti,ab. (2798)   138 3     (sex adj3 tour*).ti,ab. (107) 4     brothel*.ti,ab. (226) 5     (sex adj2 industry).tw. (323) 6     (anti adj3 prostitut*).ti,ab. (14) 7     escort.ti,ab. (118) 8     (call adj2 girl).tw. (14) 9     (anti adj3 prostitut*).ti,ab. (14) 10     (sex adj3 buy*).ti,ab. (64) 11     (commercial adj3 sex*).ti,ab. (764) 12     or/1-11 (4465) 13     Uganda.tw. (1835) 14     (northern adj province).ti,ab. (67) 15     (West adj Nile adj Province).ti,ab. (0) 16     (West adj Nile adj District).ti,ab. (0) 17     (West adj Nile adj sub-region).ti,ab. (0) 18     (Kampala or Kira or Mbarara or Mukono or Gulu or Nansana or Masaka or Kasese or Hoima or Lira or Mbale or Masindi or Njeru or Jinja or Entebbe or Arua or Wakiso or Busia or Iganga or Mpondwe or Kabale or Soroti or Mityana or Mubende).ti,ab. (318) 19     or/13-18 (1954) 20     12 and 19 (22)  Sociological Abstracts via Proquest  1952-present  uganda AND (sex work* OR prostitut*) uganda AND SU.EXACT("Prostitution")  ProQuest Dissertations & Theses Global  (TI(Prostitution) OR TI(prostitute) OR TI(sex buyer) OR TI(sex work) OR TI(brothel) OR TI(sex industry) OR TI(anti-prostitution) OR TI(escot) OR TI(commercial sex) OR AB(Prostitution) OR AB(sex work*) OR AB(brothel) OR AB(sex industry) OR AB(anti-prostitution) OR AB(escot) OR AB(commercial sex)) AND (TI(Uganda)OR TI(Africa) OR AB(Uganda))   Econlit via Proquest  (TI(Uganda) OR AB(Uganda)) AND (prostitute OR prostitution OR sex worker OR sex work)   IDEAS via https://ideas.repec.org/search.html  IDEAS uses the RePEc database. RePEc stands for "Research Papers in Economics" and is an internal name for a group working on the provision of electronic working papers.   Uganda + ("sex worker" | prostitute | "sex work" | prostitution)   139 Searched whole record, synonyms, all years   BLDS British Library for Development Studies via http://www.ids.ac.uk/publications/search/ Repository of reports and publications in the area of global poverty and injustice  Search terms:  Uganda, sex worker, prostitute, sex work, prostitution, brothel, sex industry   Web of Science Core Collection: Citation Indexes  Science Citation Index Expanded (SCI-EXPANDED) --1900-present  Social Sciences Citation Index (SSCI) --1900-present  Arts & Humanities Citation Index (A&HCI) --1975-present  Conference Proceedings Citation Index- Science (CPCI-S) --1990-present  Conference Proceedings Citation Index- Social Science & Humanities (CPCI-SSH) --1990-present  # 3 118 #1 AND #2 Indexes=SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH Timespan=All years # 2 124,253 TI=(prostitute OR prostitution OR sex worker OR sex OR brothel OR sex industry) Indexes=SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH Timespan=All years # 1 15,916 CU=Uganda OR TI=(Uganda or Kampala or Kira or Mbarara or Mukono or Gulu or Nansana or Masaka or Kasese or Hoima or Lira or Mbale or Masindi or Njeru or Jinja or Entebbe or Arua or Wakiso or Busia or Iganga or Mpondwe or Kabale or Soroti or Mityana or Mubende) Indexes=SCI-EXPANDED, SSCI, A&HCI, CPCI-S,   140 CPCI-SSH Timespan=All years   Health Evidence (database of public health systematic reviews) http://www.healthevidence.org/default.aspx Search term:  Uganda   CAB Direct (CAB Abstracts & Global Health) "sex workers" OR "prostitution" OR "prostitutes" AND "Uganda"                 141  Appendix B  : Overview and characteristics of qualitative studies on sex workers in Uganda Source Setting Design Objective Sample size and characteristics Results Gysels, 2001 Trading town in south-western Uganda  Qualitative: semi-structured interviews  Examining the sexual cultural drivers and mediators among commercial sex workers at a roadside truck stop  N=12 Ugandan sex workers  Themes: Truck drivers (clients) use 'middle men' to connect them to sex workers. Sex workers reported preferring ‘middle men’ because they professionalize the transaction and help to ensure that the driver will pay and use condoms.   Gysels, 2002 Trading town in south-western Uganda Qualitative: life histories  Examining the sex work environment on trans-Africa highway in southwest Uganda  N=34 Ugandan sex workers  Themes: sex working environments included 1) sex work in back-street bars only; 2) waitress in bars who engage in sex work; 3) women who own their own bar and engage in sex work. Domestic violence with non-commercial partners was common (82.35%) and consistent condom use was more difficult to negotiate with regular partners    142 Source Setting Design Objective Sample size and characteristics Results Ntozi, 2003 Kampala, Kabale (western Uganda), and Lira (northern Uganda)  Qualitative: 3 focus groups with sex workers   Investigating sexual behaviour change among sex workers and other key affected populations (male/female adolescents, male/female street children, truck drivers, barmaids, sex workers  N=30 sex workers in 3 focus groups  Themes: Sex workers reported that poverty led them to sex work, inconsistent condom use is more common with regular partners than casual or one time. Client violence and condom refusal is common. HIV testing was harder to find in Lira, northern Uganda.    143 Source Setting Design Objective Sample size and characteristics Results Zalwango, 2010 Kampala  Qualitative: life histories, 7 repeated interviews over 6 months  Documenting pathways into sex work through marital separation, supporting children, and migrating to Kampala for a higher urban wage  N=96 Ugandan sex workers  Themes: The money women receive from selling sex and other work helped them to independently pay for their housing children’s school fees, and food for their family without receiving support from partners. In their narratives women portrayed themselves as mothers, wives, partners, friends and workers with self-esteem and the hope of improvement in their lives through their own efforts.    144 Source Setting Design Objective Sample size and characteristics Results Schoemaker, 2012 Kampala  Qualitative: ethnographic   N=68 Ugandan sex workers  Themes: Benefits of sex work included higher income, independent working schedule. Risks include dangerous work place, violent clients (physical and sexual violence - including gang rape), police be physically and sexually aggressive. Social discrimination from public, families, and service providers. Poverty drives unprotected sex, more urgent to get money to support then family than to worry about HIV    145 Source Setting Design Objective Sample size and characteristics Results Mbonye, 2012 Kampala  Qualitative: life histories  Investigate sex workers gender relations from childhood to adult life and how it led them to sex work  N=58 Ugandan sex workers   Themes: Many sex workers experienced childhood adversity - neglect, abuse from parents and teachers. Early unwanted pregnancy led many to leave school. Needing to earn money for childcare was main reason for starting sex work. Violence from clients and police was common  Mbonye, 2013 Kampala  Qualitative: 3 in-depth interviews per participant  Exploring key risk factors associated with different sex work environments. N=58 Ugandan sex workers   Themes: Common sex work solicitation venues included street/roadsides, bars and nightclubs. Common service venues included lodges, bars, dark alleyways or parking lots. Outdoor locations were more dangerous - increased violence, police harassment, stigma from public    146 Source Setting Design Objective Sample size and characteristics Results Scorgie, 2013 Multisite: Uganda (Kampala), Kenya, South Africa, Zimbabwe  Qualitative: 55 in-depth interviews, 12 focus groups  Exploring the impact of violence and related human rights abuses on the lives of sex workers, and how they have responded to these conditions, as individuals and within small collectives.  N= 136 sex workers,  female (n=106), male (n=26) and transgendered (n=4); n=25 sex workers from Ugandan    Themes: Client violence is a common threat and includes physical and sexual violence and client condom refusal. Policing was common and included being harassed, beaten and/or sexually assaulted by police, legitimized through criminalization. Sex workers often needed to exchange sex to get help from authorities, including landlords and brothel owners. Collective organization is difficult with mobile populations     147 Source Setting Design Objective Sample size and characteristics Results Scorgie, 2013 Multisite: Uganda (Kampala), Kenya, South Africa, Zimbabwe  Qualitative: 55 in-depth interviews, 12 focus groups  Exploring sex workers experience of seeking care in public and private clinics, and how services can be improved.  N= 136 sex workers,  female (n=106), male (n=26) and transgendered (n=4); n=25 sex workers from Ugandan   Key unmet health needs included diagnosis and treatment for sexually transmitted infections and insufficient access to condoms and lubricant. Denial of treatment for injuries following physical assault or rape and general hostility from public-sector providers was common. When possible, sex workers attended private services, citing higher quality and respect for dignity and confidentiality. Participants called for the decriminalization of sex work to help reduce stigmatisation, particularly to transgender and male sex workers. Alongside law reform, sex worker advocated for peer-led outreach.    148 Source Setting Design Objective Sample size and characteristics Results Nyanzi, 2013 Kampala and IDP camps in northern Uganda  Qualitative: ethnographic, participant observation, repeat in-depth interviews, focus group, policy review, media analysis  To explore sexual minority and sex work experiences within the HIV response among refugees in Uganda  N=54 male, female, transgendered and queer refugees involved in sex work  Themes: Violence from clients was very common, including homophobic rape, gang rape, and being drugged. Policing was an extra concern among refugees because of statelessness. Poverty was driving unprotected sex. Criminalization of sex work and homosexuality limiting access to care from all sources (UN, government, NGO)  Mbonye, 2014 Kampala  Qualitative: 3 in-depth interviews per participant  Assess the magnitude, driving factors and consequences associated with alcohol consumption among sex workers  N=40 Ugandan sex workers  Themes: Many began drinking as an emotional coping strategy and to gain courage to engage in sex work. Consquences of alcohol use included difficulty negotiating condom use, clients buying sex workers drinks in place of paying for sex, and intoxicated clients were more violent    149 Source Setting Design Objective Sample size and characteristics Results Marlow, 2014 Kampala  Qualitative: in-depth interviews  Investigating sex workers experiences with post-abortion care  N=9 Ugandan sex workers who just had an abortion  Themes: Most common reasons for abortion included: not knowing father, consequence of rape, could not afford another child. Stigma against sex workers and the stigma of having an abortion was a dual barrier to care Lees, 2014 Multisite: Uganda (Kampala)/Tanzania  Qualitative: semi-structured interviews  Investigating the drivers and motivations for intervaginal practices  N= 176 sex workers,  n=96 from Uganda  Themes: intervaginal practices (douching, cleansing with soap/water, inserting herbs) were motivated by overlapping concerns with hygiene, morality, sexual pleasure, fertility, relationship security, and economic security  

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