Gender, Transactional Sex and HIV Prevention Cascade Engagement Among Urban Refugee and Displaced Adolescents and Youth in Kampala, Uganda: Implications for Advancing Sexual Health

Background and Purpose: Half of the world’s 70 million forcibly displaced persons are under 18 years, live in urban areas, and most experience social and economic marginalization. Poverty, precarious legal status, and limited formal employment opportunities contribute to selling sex among refugee and displaced persons. Stigma and violence among refugee sex workers harms sexual health, including elevating HIV vulnerabilities. Transactional sex among urban refugee youth is understudied, particularly regarding gendered experiences. We examined associations between transactional sex and HIV prevention outcomes among urban refugee and displaced adolescents and youth in Kampala, Uganda.

Methods: We conducted a cross-sectional survey with a peer-driven sample of refugee/displaced adolescent girls and young women (young women) and adolescent boys and young men (young men) aged 16-24 living in Kampala’s informal settlements. We conducted gender-disaggregated analyses. First, we conducted bivariate analyses to examine differences by past 12-month transactional sex engagement for HIV prevention outcomes (lifetime HIV testing; condom self-efficacy; recent [past 3-month] consistent condom use [CCU]). Second, we conducted multivariable linear (condom self-efficacy) and logistic (lifetime HIV testing; recent CCU) regression to examine associations between transactional sex and HIV prevention outcomes, adjusting for sociodemographic factors.

Results: Among 324 young women (mean age: 19.31, SD: 2.56), one-quarter (n=86; 26.5%) reported transactional sex (67.4% for money only, 32.6% for money and other goods). Among transactional sex-engaged young women, 62.8% reported lifetime HIV testing and 73.8% reported recent CCU. Among 88 young men (mean age: 20.45, SD: 2.51), nearly half (n=42; 47.7%) reported transactional sex (21.4%: money only; 78.6%: money and other goods). Among transactional sex-engaged ABYM, 50.0% reported lifetime HIV testing and 53.3% reported recent CCU. In multivariable analyses, transactional sex-engaged young women reported significantly higher condom self-efficacy (β=0.21, p<0.0001, 95%CI=2.07, 5.89) and increased odds of recent CCU (aOR 7.83, 95%CI=3.63, 16.82) than non-transactional sex involved young women. Transactional sex was not associated with young women's lifetime HIV testing (aOR 0.76, 95%CI=0.42, 1.37). Among young men, transactional sex was not associated with condom self-efficacy (β= -0.09, p>0.05, 95%CI = -3.35, 1.26) or recent CCU (aOR 0.49, 95%CI= 0.14, 1.74). Transactional sex was associated with lower lifetime HIV testing odds (aOR 0.32, 95%CI= 0.11, 0.89): young men were 68% less likely to have tested for HIV if reporting transactional sex.

Conclusions and Implications: Transactional sex among young women was associated with improved condom outcomes—suggesting HIV prevention engagement—yet among young men was linked with lower HIV testing. Findings highlight urgent HIV testing gaps among transactional sex-engaged urban refugee and displaced youth who fall far below the UNAIDS goal of 90% of people knowing their HIV status. Refugee sex worker agencies for women in Kampala may enhance sexual agency among young refugee women; providing similar programs for sex working young refugee men could likewise advance sexual health. Multi-level, gender-transformative, and sex work affirming interventions informed by the HIV prevention cascade framework can increase HIV prevention demand (e.g. awareness), supply (e.g. access), and adherence (e.g. self-efficacy). Findings demonstrate an urgent need for sexual health promotion tailored for urban refugee and displaced youth.