Key Populations (KP) in Uganda Come of Age and Ask the Right HIV Prevention Questions as They Navigate Optimal Outcome paths

One working in the HIV Prevention & Care Service Delivery in Uganda, will easily note that the CSOs involved experience a milestone disparity as they sprint toward the UNAIDS 95:95:95 goal.

Imagine there are two sprinters asked to race forward to the finish line. One has their hands tied and the other is free.  It would be preposterous to expect a victory from the one with the hands tied. 

KP-Led Organizations in Uganda face cumbersome barriers which they need to go over to be effective. The major question raised by funders is how to maintain ARVs medication to ensure optimal viral suppression in Persons Living With HIV. But, for KP-Led organizations this goal is arrived at after asking vulnerability and susceptibility-related questions.

A qualitative analysis of reports from 44 KP-led organizations was done. The aim was to find the underlying subjective characteristics linked to achieving HIV Prevention optimal outcomes.

The exercise revealed interesting findings. The readiness to roll out effective HIV Prevention activities hinges on facilitation for organization development. KP-led organizations served beneficiaries with the goal of availing opportunities for access to ARV service providers. There are navigation paths which needed to be addressed as well. These are further divided into the proximate and distal parts with underlying subjective causes and processes (factors).

The proximate causes were defined as actionable attributes of availability and use e.g., presence and taking of the medication. The proximate processes involved time and task oriented activities e.g., time for taking prescription, actual taking of a prescription, availability of food or water necessary for beneficial drug action.

At the distal part were structural and environmental factors e.g., no immediate threats or barriers to one’s taking medication, price, political conditions, social status, stigma, discrimination, harassment, availability of health facilities to ensure refills and regular supply of medicines before stocks run out.

Beneficiaries of KP-led organizations in Uganda, have the following characteristics: unstable housing, have difficulties paying for transport to go to clinics for regular check-ups or refills. The likelihood of facing stigma and discrimination in their domicile communities and at other points of call is so high. These conditions combine into what are known as a Vulnerability and Susceptibility Chain (VASC). VASC in turn opens ways for poor or no possibility to negotiate for safer sex, a possibility for abused partners in a relationship to remain silent about abuses, high likelihood of HIV transmission, poor ARV-adherence and subsequent lack of viral suppression.

But, what can be done to address VASC? 

There are three compelling answers.

The first was to allow KP-led organizations to establish viable groups. These should be facilitated to go through organization development trainings. This in turn would improve their readiness to become effective HIV Prevention actors. It would create a durable prevention culture enabling access to HIV Testing, put those with positive diagnosis on ARVs and ensure those on ARVs adhere so that they experience viral suppression over time. There are added advantages in being part of support groups. It means that people who choose to form, join and maintain viable groups, enjoy many advantages. The advantages range from companionship, building self-esteem, assurance of stable housing, affinity to caring for others and motivation to commit to ARV adherence for those with positive diagnosis. This in turn addresses what is known as Generalized Anxiety Disorder (GAD) known to be faced by PLHIV who are not cared for or who fail to seek care services. This too is associated with lower rates of HIV treatment, adherence to treatment and very poor or no viral suppression, according to Benjamin Ryan (2019) in an article titled “A High Proportion of People with HIV Suffer from Anxiety,”

The second was to enroll in Clinical Trial Programmes that are available in the country. This increases opportunities for regular monitoring and evaluation by well trained and qualified health workers.

The third was to embrace new health technologies that increase opportunities for avoiding breaks in taking ARVs e.g., for vulnerable women and girls. One such example is the vaginal ring. In an article by Roxy de Villiers (2019) titled “The quest for the (vaginal) ring,” the “a vaginal ring inserted monthly could reduce women’s risk of contracting HIV, it is a long-acting form of treatment that HIV-negative women can take before being exposed to HIV to reduce their chances of contracting the virus.”

The above three suggestions combine as opportunities for KP-led organizations in Uganda to promote the taking ARVs as prescribed both easier said and done.

Key Populations (KP) And Fistula, What Is The Link?

When one hears of Fistula, the next thing that comes to mind could be pregnancy and childbirth. 

But, all of us should be concerned.

There is a vulnerability and susceptibility in the event one is sexually active before the age of 18 years,  a victim of physical assault, rape, engages in use of sex toys, inserting or stashing objects in the vagina and anus during sexual play, torture or as a result of hiding objects that may be contraband.

But, why should Key Populations (KP) be exceedingly concerned?

There are six reasons why KP should be emancipated enough to contribute to reduction of Fistula cases in their communities.

1. It is treatable and those who seek care go on to lead confident fulfilling lives.
2. It affects a big number of people than previously known.
3. Contributing to its reduction, means improving health and achievement of the SDGs.
4. You may be called upon to take care of someone after surgery. You need to know what they go through.
5. It does not hurt to know or be informed about Fistula.
6. Because you may be a human Rights Defender and your task is to advocate for dignity of all persons. 

According to the WHO (2019) report, Obstetric fistula is preventable; it can largely be avoided by:

• delaying the age of first pregnancy;
• the cessation of harmful traditional practices; and
• timely access to obstetric care.

There are many resources one can use to get information on fistula condition. In a resource by Amie (2019), symptoms and types of fistula are listed.

Symptoms:

Symptoms of fistulas vary depending on their location and severity. However, some symptoms are common in most cases. People often feel very unwell and run a fever. They also feel pain or tenderness at the site of the fistula. Itching may develop, especially if the fistula involves skin. Fistulas often exude pus, which may have an unpleasant or foul smell.

Risk Factors: 

Certain conditions place a person at a higher risk of developing a fistula. Crohn's disease and diverticular disease are two conditions highly likely to cause fistulas. Around one in three people with Crohn's disease will get a fistula at some point. Certain cancer therapies, in particular, radiation therapy, can make fistulas more likely to form. An unusual cause of enterovaginal fistulas is obstructed labor when doctors delay intervention for too long. This is rare in the United States as women usually receive a high level of care during childbirth.

Sepsis: 

If left untreated, fistulas can become chronic. They can also cause sepsis, a potentially life-threatening condition that develops when the immune reacts to an infection. Symptoms of sepsis include a high-grade fever, a rash, and confusion. It can also result in a fast heart and breathing rate. Sepsis is a medical emergency and requires immediate hospital treatment.

Treatment with Enteral Diet:

Doctors may prescribe enteral diets to those with fistulas in the small or large intestines. When a person is on an enteral diet, they will consume only liquid food for a period. They may require a feeding tube. This type of diet ensures one receives all the nutrients they need without taking in any solid food, thus reducing the amount of stool passing through the intestines and rectum. With this treatment, the fistula has a chance to heal and may even close on its own.

Surgical Intervention:

If the fistula is large or does not respond to less invasive treatments, it will require surgical removal or repair. Where possible, surgeons will use laparoscopic methods, inserting cameras and tools through very small incisions. However, some fistulas require transabdominal surgery involving larger incisions in the abdominal wall. In some cases, a fistula may develop in a diseased part of the bowel. Doctors may resection the bowel and remove the diseased section, including the fistula. In this situation, the person may require a pouch after surgery. This will temporarily divert stool away from the resectioned area to give it time to properly heal.

Statistics: 

Preventing and managing obstetric fistula contribute to the Sustainable Development Goal 3 of improving maternal health.

According to fistualfoundation.org, there are over one million women suffering from obstetric fistula worldwide. Fistula is most prevalent in sub-Saharan Africa and Asia.

Fewer than 6 in 10 women in developing countries give birth with any trained professional, such as a midwife or a doctor. When complications arise, as they do in approximately 15% of all births, there is no one available to treat the woman, leading to disabling injuries like fistula, and even death.

The root causes of fistula are grinding poverty and the low status of women and girls. In developing countries, the poverty and malnutrition in children contributes to the condition of stunting, where the girl’s skeleton, and therefore pelvis as well, do not fully mature. This stunted condition can contribute to obstructed labor, and therefore fistula.

Obstetric fistula is both preventable and treatable. It can be prevented if laboring women are provided with adequate and timely emergency obstetric care when complications arise. Once a fistula has developed, however, the only cure is surgical treatment.

In the WHO (2019) report, each year between 50,000 to 100,000 women worldwide are affected by obstetric fistula. The development of obstetric fistula is directly linked to one of the major causes of maternal mortality: obstructed labour.

Women who experience obstetric fistula suffer constant incontinence, shame, social segregation and health problems. It is estimated that more than 2 million young women live with untreated obstetric fistula in Asia and sub-Saharan Africa.

Definitions:

The most common fistulas are listed. A fistula occurs when two organs or structures within the body form an abnormal connection. Fistulas can begin in various ways, but many start as an abscess. Abscesses are pus-filled pockets of tissue. Gradually, the abscess may fill with a bodily fluid such as urine. After a while, the abscess invades another structure in the body. This connects the two structures and forms a fistula. You can think of it as a tunnel that should not be there. Fistulas are most common in the abdomen but can occur anywhere in the body. 

Enterocutaneous fistulas connect the small intestine to the skin. They often result from surgical complications. 

Enteroenteric or enterocolic fistulas involve either the small or large intestine connecting to another structure in the body. 

Enterovaginal fistulas are fistulas involving the vagina. 

Enterovesicular fistulas enter the bladder and can cause the person to contract frequent urinary tract infections.

A fistula:

A fistula is a hole, or abnormal opening, in the birth canal, that results in chronic leakage of urine and/or feaces.

Obstetric Fistula:

 An abnormal opening between a woman’s genital tract and her urinary tract or rectum.

According to fistulacare.org, each year, more than a quarter million women die in pregnancy and childbirth. Of those that do not perish, an unknown number suffer long-term health problems. The maternal injury with perhaps the most devastating aftermath is obstetric fistula. 

Obstetric fistula due to obstructed labour is by far the most common form of genital fistula, constituting an estimated 80-90% of all genital fistula cases. 

Obstetric fistula is usually caused by several days of obstructed labor, without timely medical intervention or cesarean section. During this time, the soft tissues of the pelvis are compressed between the baby’s head and the mother’s pelvic bones. The lack of blood flow causes tissue to die, creating a hole between the mother’s vagina and bladder or between the vagina and rectum, or both, and resulting in leakage.

Left with chronic leaking, women with obstetric fistula are often abandoned or neglected by their husbands and families, unable to work, and ostracized by their communities. Women who develop obstetric fistula usually have had a stillbirth, so they must also deal with the loss of a baby. Women with fistula are often among the most impoverished and vulnerable members of society.

Iatrogenic Fistula:

Sometimes genital fistula can be caused unintentionally by a health care provider. This type of injury is called iatrogenic fistula. For instance, during a cesarean section, it is possible that the bladder is accidentally cut, resulting in a hole or abnormal opening through which urine leaks.

Iatrogenic fistula can also occur by accident during surgeries unrelated to childbirth. In many of the countries where we work, approximately 10-15% of the overall patient caseload is due to iatrogenic causes. Training surgeons and other health care staff in emergency obstetric care and other surgical skills is essential to preventing new cases of iatrogenic fistula.

Traumatic Fistula

Traumatic fistula is a condition that can occur as the result of sexual violence, often in conflict and post-conflict settings. There are no solid estimates of its prevalence, but traumatic gynecologic fistula can make up a significant part of the overall genital fistula caseload in places where sexual violence has been used as a weapon of war.

Rape, often aggravated by the thrusting of objects into the vagina or anus, can result in a hole between a woman’s vagina and bladder or rectum, or both, resulting in the leaking of urine and/or feces. 

Survivors of sexual assault may have additional, severe physical injuries and are at an increased risk for unwanted pregnancy and sexually transmitted infections, including HIV. 

Survivors live not only with chronic incontinence, but also with the psychological trauma and stigma of rape.

Fistula is life-shattering: Women contend with chronic incontinence and often are ostracized by their husbands, families, and communities. The good news is that fistula can be completely repaired up to 90% of the time if fistula survivors have access to a trained surgeon at a hospital providing fistula repair.

Beyond surgical repair, other needed support includes comprehensive counseling and physiotherapy, as needed, as well as treatment of concurrent disabilities. When repaired women leave a health facility, there is need to link them to community-based organizations that support their reintegration back into their community.

Human Rights Defenders Can Contribute to Prevention of Fistula

Prevention

Many of the approaches that prevent obstetric fistula are the same ones that make motherhood safer in general.  Engage with your community or advocate for improved Health facility services. Improving maternal health, strengthening obstetric care and facility-based prevention work focuses on:

Family Planning

Family Planning allows couples to delay early births, space desired births, and limit family size. Up to one-third of all maternal deaths and injuries could have been prevented if women had access to contraception. Family planning can also help women with a repaired fistula achieve a successful pregnancy, if that is their desire, by helping them delay a future pregnancy until they are fully healed. Women who have experienced repair are generally advised to abstain from sexual relations for a period of time to allow them to heal. In some situations, for some women find it difficult to comply with this recommendation. Other women may need a longer time before they are able to successfully sustain a pregnancy, and family planning methods can help couples determine when is the best time to get pregnant.

Promotion of the Partograph

The partograph is a low-tech tool for preventing and managing prolonged or obstructed labor, a significant cause of reproductive morbidity and mortality. It is a preprinted one-page form on which observations of the progress of labor and information about maternal and foetal condition are recorded. 

The partograph is designed to act as an “early warning system,” alerting doctors, midwives, and nurses to the need for action—e.g., referral to a higher level facility, labor augmentation, or cesarean section. Correct and consistent use of the partograph has the potential to reduce obstructed labor and its adverse consequences, including fistula.

Immediate Catheterization

If a woman with obstructed labour arrives at a hospital and is believed to be at risk for obstetric fistula, immediate catheterization can help to prevent the fistula from developing. The catheter should remain in place until well after the end of labour.

Cesarean Section

Timely Cesarean Section is critical for women with obstructed labor. Doctors performing a cesarean delivery must be competent so that they do not inadvertently create an iatrogenic fistula. Fistula Care Plus works with hospitals to ensure that quality cesarean sections are available from trained health professionals.

Community-Based Prevention

Be part o the effort preventing fistula at the community level. Activities include social mobilization and awareness-raising campaigns, dramas and broadcasts about the importance of antenatal care and assisted delivery, and support for transportation and referrals.

Remember, you too can contribute to preventing Fistula

For more you can follow these links:

https://www.engenderhealth.org/files/pubs/fistula-care-digital-archive/7/7.4/Uganda_TWG_TB_ENGLISH.pdf

https://www.prb.org/ugandasfistulapatientslackknowledgeofpreventionandtreatment/

https://www.fistulafoundation.org/what-is-fistula/fast-facts-faq/

https://facty.com/ailments/body/10-facts-about-fistulas/10/

https://www.who.int/features/factfiles/obstetric_fistula/en/

https://fistulacare.org/what-is-fistula/prevention/

Underlying KP-related HIV Prevalence Is Susceptibility To Consequences Of Persecution And Relocation

Migration, mobility and marginalisation have consequences for Sexual and Gender Minorities according to studies.

People engage in, execute activities, associate, move or voice their needs to seek fulfilment. This fulfilment could be escape from persecution, desire to seek greener pastures, desire to be part of communities, brevity, valour, recognition, daring or curiosity and self preservation. These are private interests which constitute the subjective filters or basis for negotiating how one can enjoy public spaces. This negotiation comes as narration;  commodification; labour or skills which enable one to engage in problem posing or solving; and coping with challenges. 

"As a strategy to avoid discrimination, violence and economic marginalisation or persecution, sexual and gender non-conforming people often turn to migration as a route to achieve independence and build social capital. Recent studies by the IDS Sexuality, Poverty and Law programme demonstrate that while migration can provide liberation from some experiences of marginalisation and an ability to contribute economically towards family households, for many it leads to a precarious existence. To ensure these groups are not ‘left behind’ in development, policymakers and aid programming must recognise and address marginalisation of these groups as part of overall strategies to reduce risks of migratStudies undertaken by the IDS Sexuality, Poverty and Law (SPL) programme in 15 countries demonstrate that the effects of social, economic and political marginalisation can ‘force’ people to move either within their country or overseas. People can also choose to migrate for strategic reasons in order to counteract existing marginalisation, by moving to more accepting locations where they can economically contribute to families remotely and express their identities freely.Traditionally, there is a greater likelihood of movement from smaller towns or rural communities to urban contexts. This is primarily due to greater financial prospects being available in urban as opposed to rural contexts as labour tends to flow naturally from low-wage regions to high-wage areas. For many, migration might necessitate a move as economic migrants, refugees or asylum seekers to more tolerant countries where opportunities for a safe, authentic and economically productive life are more possible. An increasing number of countries are now considering persecution of homosexuality as a ground for seeking asylum, although there is now a body of documented cases highlighting how the process can be onerous, inappropriately intrusive for applicants and has low rates of succession.

In some countries, activists operating in nascent lesbian, gay, bisexual, transgender and intersex (LGBTI) organisations can find themselves forced to leave their countries as a result of their campaigning. Establishing a life within a new environment allows individuals to cast aside some of the social expectations and surveillance that characterises the lives of gender and sexual nonconforming individuals, although rigid gender norms may still impact on their lives.

The choice to migrate entails balancing the risk of discrimination at home with the potential loss of established social networks. For many, the loss of existing networks at ‘home’ can be offset by the formation and growth of fresh networks amongst their peers following migration to another city or country. These can allow them fresh opportunities to access resources and build social capital amongst other sexual and gender non-conforming individuals. That said, moving away from one’s family or community inevitably involves some loss of status and informal assistance that others would take for granted in making their way in the world.

Policy recommendations 

Whilst migration has challenges for everyone who attempts it, there are particular measures that would assist in ensuring it has a positive impact on economic and social prosperity of sexual and gender minority communities:

 • International organisations should become more sensitive to the reality that all international development activity affects those with non-normative sexual and gender identities and reflect this in their approach in designing, assigning resources and measuring the effectiveness of all aid programming.

 • International donors should introduce mechanisms to support ‘underground’ forms of LGBTI activism, even when this is with young organisations that might represent a small element of financial risk or where measurements of success are harder to quantify.

 • Same-sex relations should be decriminalised as a step towards securing the social, political and economic rights of gender and sexual non-conforming individuals and shifting public and familial attitudes.

 • Development programmes should not aim to discourage migration or sex work (and other forms of livelihood strategies), but instead work to resolve the multiple barriers faced by gender and sexual minorities, alongside offering diverse skills training, language and employment options.

 • Invest in research that helps to provide a greater understanding of the particular experiences of gender and sexual minorities living in rural contexts, as current evidence around exclusion is dominated by that undertaken in urban contexts. In addition, policymakers should make recommendations for improvements that can mitigate the push-and-pull factors that encourage migration.

 • Support strategies to simplify the process of obtaining identification papers for people from gender and sexual minorities (such as sex workers) who need to migrate regularly.

 • Invest further in increasing population research studies around social mobility and migration of gender and sexual non-conforming individuals.

 • Encourage and fund time for LGBTI organisations to form strong alliances with the rest of the international SOGIE (sexual orientation and gender identity and expression) community (especially regional partnerships), so that when individuals migrate to another country there is a network available to support them in the transition and the possibility of joint campaigning around common issues."

With Increasing Privatization And A Young Population Explosion In Africa, Micro-Credit Extension Can Play Quality Life Improving Roles

As governments increasingly privatize, microcredit extension can be used to foster development and increase SRH And RMNCAH uptake among Ugandan Youths 13-35 years.

Background: African Governments need to increasingly use Microcredit or Micro finance services as precursors and catalysts for many other social services and development goals. This has outcome implications in many areas including:HIV, SRH, RMNCAH and increasing household level living standards. The aim of the report is twofold: explore the categories that made Microcredit a catalyst for quality life practices; how Key Populations (KP) can use Microcredit to engage in quality life improving practices.

Methods: Community immersion, literature review and key informant interviews were used to generate the report between December 2015-February 2019 in 15 Ugandan Town Councils. 230 respondent were eligible out of 330. Eligibility was based on age; 5-7 months grace period after first loan withdrawal; small interest on loans ranging 0.002-0.009%; membership to more than one group or social collateral; did not have to deposit money in bank as collateral; plans set aside to ensure food sustenance; number of months in business between 6 months and 3 years; had plans for long term investments; and requested first/kick-starter loan equal to or below Ugx. 2,000,000.00. 

Results: All 230 with median age 26(IQR (13-35) reported self employment for past two years, flexibility to innovate, engage in self care and saved for food. One hundred seven (107/230) tested for HIV at least five times in 2018. A disaggregation of respondents: 101 Straight females; 90 Straight males; 22 Transgender; 7 Lesbians; 20 Gay males. All respondents were below 35 years. 53 with median age 22 (IQR13-35) were living with HIV among whom 7 are Transgender; 5 are Gay males. Microcredit supports participation in quality life practices, ability to form, maintain collateral viable groups and links businesses in the service sector that follow market demands. These businesses were linked into food consumption (72) operated a food kiosk- and a side grocery) with median age 27 (IQR 23-35); telephone kiosks operation (25) with median age 19 (IQR 13-35); attire and shoes (22) with median age 20(IQR 13-35); movie kiosk (8) artisanry (12); brick-making (32); carpentry (9); Boda-riders (7) with median age 23 (IQR 13-35); event planning and hosting (23) with median age 30(IQR 23-35); stationery (27) with median age 25 (IQR22-35); grocery shops (20) with median age 27 (24-35); and commitment to nurture goodwill and credibility e.g. return the money. 

Conclusions and Recommendations: Young people can be empowered to engage in SRH uptake. Microcredit extension catalyzes market linkage, increases citizen self preservation provisions, is linked to opportunities for social integration, through entrepreneurship and wealth creation. It increases Household income base, a precursor for self care. Age is linked to service sector start-ups and ventures. More younger people are living with HIV. The role party politics plays in addressing young persons’ concerns needs further study.

KP-led HIV Prevention Programming That Achieves UNAIDS 95:95:95 Outcome Strategies: Ugandan KP Demography

Key Population-led and mentored formulation of HIV Prevention interventions in Uganda is both targeted and evidence-based driven as Well. But, what exactly are these interventions?

There are basic outcome strategies KP-led organizations in Uganda can adopt if they were to be effective change agents cascading into UNAIDS 95:95;95. 

Working hand on hand and allowing KP-led organizations in Uganda participate in verbalizing, designing, visibilizing and mainstreaming what works is commendable. It is the only sure way to also ensure PEPFAR HIV Preventions funds are well spent. Allowing them to access funding has leveled the HIV Prevention ground. This is commendable indeed.

For most of the organizations, it will be an opportunity for autonomy and self-directed agency. For the money to be spent on efforts to eradicate HIV, there is need to include self assessment. Researchers in Uganda who have sent over 20 years working with KP designed a 6W1H model (What, Who, Where, Why, When, Which & How).

This allows organizations to conduct readiness examination into how effectively they could operationalize or implement HIV Prevention services. 

The aim of this report is to link research into KP Programmatic interventions to quality health and evidence-based goals. With this model, KP-led organizations will devise and own ways to make HIV Prevention roll out to meet UNAIDS 2030 Goals.

An effective plan must maximize opportunities to meet UNAIDS 2030 Goals. This is possible when organizations go through participatory reflexive/deflective roles with the aim of creating optimizing activities for PEPFAR/KPIF funds to be spent on the outcome strategies:

Treatment 

• As far as TB/Malaria/Hepatitis/HIV what latest information, Education, Communication (IEC) does my organization have? What does my Social Activities Map (SAM) show as a strategy to serve my catchment area so well? Who exactly are we linking to care and other social services? Who do we meet as far as social services go? Who among us is the liaison with the social services Providers? Where do we refer our beneficiaries? Where do our beneficiaries reside? Why do we spend time, money and resources eradicating TB/Malaria/Hepatitis/HIV? Which areas do we need to invest more time, money and resources? How can we connect with other organizations as part of referral and networking?

Prevention

• There is Primary, Secondary and tertiary Prevention. CBOs are more concerned with Primary Prevention. As far as TB/Malaria/Hepatitis/HIV is concerned, what latest prevention information, Education, Communication (IEC) does my organization have? What does my Social Activities Map (SAM) show as a Prevention strategy to serve my catchment area so well? Who exactly are we linking to Prevention Services as well as other social services? Who do we meet as far as Prevention social services go? Who among us is the liaison with the social services Providers? Where do we refer our beneficiaries? Where do our beneficiaries reside? Why do we spend time, money and resources eradicating TB/Malaria/Hepatitis/HIV? Which areas do we need to invest more time, money and resources? How can we connect with other organizations as part of referral and networking?

Palliative care

• Palliative care interventions are the kind where an organization set aside time, resources and money to engage in activities that relieve symptoms and stress among beneficiaries living with long-term debilitating illnesses. What latest information, Education, Communication (IEC) on Palliative Care does my organization have? What does my Social Activities Map (SAM) show as a strategy to serve my catchment area so well? Who exactly are we linking to care and other social services? Who do we meet as far as social services go? Who among us is the liaison with the social services Providers? Where do we refer our beneficiaries? Where do our beneficiaries reside? Why do we spend time, money and resources on Palliative Care necessary for TB/Malaria/Hepatitis/HIV eradication? Which areas do we need to invest more time, money and resources? How can we connect with other organizations as part of referral and networking?

Abstinence-until-marriage programmes

• As far as abstinence goes, what latest information, Education, Communication (IEC) does my organization have? What does my Social Activities Map (SAM) show as a strategy to serve my catchment area so well? Who exactly are we linking to care and other social services? Who do we meet as far as social services go? Who among us is the liaison with the social services Providers? Where do we refer our beneficiaries? Where do our beneficiaries reside? Why do we spend time, money and resources eradicating in linking abstinence to TB/Malaria/Hepatitis/HIV? Which areas do we need to invest more time, money and resources? How can we connect with other organizations as part of referral and networking?

OVC/Youth-Headed Households below 18 years

• This area requires working with Ministry of Gender, Development & Social Development, Religious Organizations and other support CSOs. What latest information, Education, Communication (IEC) does my organization have on social development issues and concerns? What does my Social Activities Map (SAM) show as a strategy to serve my catchment area so well? Who exactly are we linking to care and other social services? Who do we meet as far as social services go? Who among us is the liaison with the social services Providers? Where do we refer our beneficiaries? Where do our beneficiaries reside? Why do we spend time, money and resources linking social issues to eradicating TB/Malaria/Hepatitis/HIV? Which areas do we need to invest more time, money and resources? How can we connect with other organizations as part of referral and networking?

Delay of sexual debut

• This is a behavioural aspect very much connected to vulnerability and susceptibility chain (VASC) risks to HIV/Hepatitis/TB/Malaria. What latest information, Education, Communication (IEC) does my organization have? What does my Social Activities Map (SAM) show as a strategy to serve my catchment area so well? Who exactly are we linking to care and other social services? Who do we meet as far as social services go? Who among us is the liaison with the social services Providers? Where do we refer our beneficiaries? Where do our beneficiaries reside? Why do we spend time, money and resources linking delaying sexual debut to eradicating TB/Malaria/Hepatitis/HIV? Which areas do we need to invest more time, money and resources? How can we connect with other organizations as part of referral and networking?

Monogamy

• This is a behavioural aspect also known as Zero-grazing. It is encouraged because it is thought having one sexual partner  lowers risk to acquiring or transmitting infections. What latest information, Education, Communication (IEC) does my organization have on monogamy? What does my Social Activities Map (SAM) show as far as a monogamy strategy goes to serve my catchment area so well? Who exactly are we linking to care and other social services? Who do we meet as far as social services go? Who among us is the liaison with the social services Providers? Where do we refer our beneficiaries? Where do our beneficiaries reside? Why do we spend time, money and resources linking monogamy to eradicating TB/Malaria/Hepatitis/HIV? Which areas do we need to invest more time, money and resources? How can we connect with other organizations as part of referral and networking?

Fidelity

• This is a behavioural aspect in which commitments and agreements are made. It is known to highlight partner support practices (PSP) such as attending life preserving sessions with a partner. When partners attend education sessions together it builds bonding and  focus to achieve goals. What latest information, Education, Communication (IEC) does my organization have on fidelity? What does my Social Activities Map (SAM) show as far as a fidelity strategy goes to serve my catchment area so well? Who exactly are we linking to care and other social services? Who do we meet as far as social services go? Who among us is the liaison with the social services Providers? Where do we refer our beneficiaries? Where do our beneficiaries reside? Why do we spend time, money and resources linking fidelity to eradicating TB/Malaria/Hepatitis/HIV? Which areas do we need to invest more time, money and resources? How can we connect with other organizations as part of referral and networking?

Counselling geared at increasing events where sex with partner is with any kind of HIV prevention method (that is with a condom, PrEP or an undetectable viral load)

• This is a milestone prevention skills development opportunity that involves committing to  life promoting or prevention activities. It is known as Prehensile Prevention Prophylactics Affirmation (PPPA). It is encouraged because use of prevention lowers risk to acquiring or transmitting infections. What latest information, Education, Communication (IEC) does my organization have on Prevention methods ? What does my Social Activities Map (SAM) show as far as Prevention methods strategy goes in order to serve my catchment area so well? Who exactly are we linking to Prevention methods counseling and other social services? Who do we meet as far as social services go? Who among us is the liaison with the social services Providers? Where do we refer our beneficiaries? Where do our beneficiaries reside? Why do we spend time, money and resources linking Prevention methods to eradicating TB/Malaria/Hepatitis/HIV? Which areas do we need to invest more time, money and resources? How can we connect with other organizations as part of referral and networking?

Partner reduction activities in any host country with a generalized (high prevalence) epidemic

• This involves avoiding toxic and precarious practices as well as deliberately reducing sexual partners. It is also best practice to familiarize yourself with country-based guidelines on how to address high prevalence. Such guidance is available from MoH and Development Partners. What latest information, Education, Communication (IEC) does my organization have on prevalence? What does my organization do to access guideline in order to serve my catchment area so well? Who exactly are we linking with? Where do we get our resources? Why do we spend time, money and resources linking resources to eradicating TB/Malaria/Hepatitis/HIV? Which areas do we need to invest more time, money and resources? How can we connect with other organizations as part of referral and networking?

There are over 107 KP organizations scattered in all over Uganda. 44 (and counting) of these also defined as sexual minorities and are registered with the Uganda KP Consortium. 

A rapid appraisal of HIV Prevention Strategies of 23 of these between 2017-2020 shows the following:

1. 14/23 of these have positioned themselves strategically for HIV Prevention but their capacity lies in the following areas: Humans Rights/Litigation Advocacy; Condom and Lubricant sourcing and distribution
2. 2/23 had conducted internal 3-5 internal meetings or short trainings for staff and during the events tasked the staff to give out Condoms and Lubricant consumables. 
3. 35/44 are Kampala-based KP-led organizations, which means they are overlapping in the catchment zone. Two (2) were Kampala-based but had outreach stations 100 miles out of Kampala City. Outreaches are a good way to put HIV Prevention facilitation to good use. There is need for deciding on zoning here.

PEPFAR And Global Fund, A History:

The U.S. is the single largest donor to the Global Fund. Congressional appropriations to the Global Fund totaled $16.6 billion from FY 2001 through FY 2018. The Global Fund provides another mechanism for U.S. support by funding programs developed by recipient countries, reaching a broader range of countries, and supporting TB, malaria, and health systems strengthening (HSS) programs in addition to (and beyond their linkage with) HIV. To date, over 150 countries have received Global Fund grants; 53% of Global Fund support has been committed to HIV and HIV/TB programs, 29% to malaria, 16% to TB, and 2% to other health issues. The original authorization of PEPFAR, and subsequent reauthorizations, included a limit on annual U.S. contributions to the Global Fund that prevented them from causing cumulative U.S. contributions to exceed 33% of the Global Fund’s total contributions; this requirement is in effect through FY 2023.

Aligning  And Stepping Up The HIV Prevention By KP:

It is clear that KP-led organizations need to be supported in realistic HIV Prevention programming and the outcome strategies below need to be mainstreamed if UNAIDS 95:95:95 goals are to be met.

1. Treatment
2. Prevention
3. Palliative Care
4. Abstinence-until-marriage programmes
5. OVC/Youth-Headed Households below 18 years
6. Delay of Sexual debut
7. Monogamy
8. Fidelity 
9. Counselling geared at increasing events where sex with partner is with any kind of HIV prevention method (that is with a condom, PrEP or an undetectable viral load)
10. Partner reduction activities in any host country with a generalized (high prevalence) epidemic

From Frying Pan To Fire: African Key Populations (KP) In A Dilemma When Provider Bias Stands In The way To Reporting IPV abuse; A Case Of Three African Cities

Alright, let us stop for a moment and analyze Key Populations (KP) vis-a-vis Intimate Partner Violence (IPV). 

Are you aware that disempowering KP from relating within their domiciliary communities across their lifespan is counter productive?

If one were to provide opportunities for KP to lead quality lives, they should not only use Heteronormative but Homonormative lenses as well. 

Disempowering by disowning, evicting, criminalizing, imprisoning, arbitrary arrests or causing harm to LGBTIPQQ children raises the likelihood of these not reaching their actualization milestones. These children undergo “what is known as children of latency who may arrive at what is termed socially decisive steps in life later in life or not at all unlike children who are allowed to grow and develop without fear of persecution. When children are denied this guidance their ideas are distorted. They may fail to form an idealized memories of adult patients who recall “the ideal of latency,” namely, the successful warding-off of instinctual impulses during this time. It is commonly agreed that the confluence of developmental and social forces propel the school-age child outward and away from the family towards peer relationships and new adult figures,” argues Wallerstein (1976).

Disempowering KP from relating within their domiciliary communities thus affects the way they relate, who they relate with, what they look for in relations, distorts self preservation goals, interrupts autonomy, agency, and eventually how they relate intimately. Studies highlighting IPV, link it to a number of traumatic causes including interruption of: sense of self, liberty, pursuance of happiness and quality life. Victims cannot engage in a full experience of life. Perpetrators on the other hand get away with it because of the muting zeitgeist around KP-related IPV. For Key Populations (KP), this has life threatening consequences.

Goodman (2005) argues that “intimate partner violence and real-life contexts of victims’ lives should be not only linked to state policy, criminal justice reforms mandatory responses focused on counseling, restraining, and punishing batterers, protection order system relying heavily on batterer treatment programs but should provide the victim support to prevent future violence. 

Contextualizing a sufferer centered focus responds flexibly to victims’ needs and providing them with advocacy and broad social support is a more successful strategy for safety of persons. o Expanding victim-centered resources and reincorporating a particularized perspective provides agency and autonomy in bringing about an end to IPV.”

Qualifications, ideas of success, achievements, money, assets, community roles, power roles, power sources education and occupational prestige, hegemonic patriarchy, masculine identity are some of the sources of agency, autonomy, self preservation, status and power of individual people. This power plays important roles in supporting or subverting relations. 

Jewkesa (2002) argues that “The way partners communicate and what they communicate about plays an important part in how they experience agreements, disagreements and how they resolve differences. verbal disagreements and of high levels of conflict in relationships are strongly associated with physical violence. Shared and personal time, resources and spaces need to be  explored by partners in order for them not to conflict. Transgression of conservative gender roles or challenges to male privilege, as well as matters of finance are another trigger of IPV.  Unlike many health problems, there are few social and demographic characteristics that define risk groups for intimate partner violence. Poverty is the exception and increases risk through effects on conflict, women's power, and male identity. Violence is used as a strategy in conflict. Relationships full of conflict, and especially those in which conflicts occur about finances, jealousy, enforcement of hierarchy and partner's gender role transgressions are more violent than peaceful relationships. Heavy alcohol consumption also increases risk of violence. Women who are more empowered educationally, economically, and socially are most protected, but below this high level the relation between empowerment and risk of violence is nonlinear. Violence is frequently used to resolve a crisis of male identity, at times caused by poverty or an inability to control women. Risk of violence is greatest in societies where the use of violence in many situations is a socially-accepted norm. Primary preventive interventions should focus on improving the status of women and reducing norms of violence, poverty, and alcohol consumption.”

So, what is the big deal here?

Even while we go about saying KP need to be targeted, we need to identify the needs in order to provide timely and effective interventions. One such need is the realization that perpetrators of abuses among KP are also holding high positions themselves and therefore are protected by the LGBTIPQQ Community. This study aimed at identifying the subjective character and typology (intrinsicness and extrinsicness) of IPV and link it to interventions targeting KP such as: access to police, courts of law, schools, recreation facilities, social spaces, jobs, credit facilities and health care. This study has policy and programmatic implications for development, educational, health, job recruiting, competitive sports, psychology, parenting and many other areas. 

Structured interviews, literature review and FGD were employed via Skype and face to face meetings. This helped to capture case by case narratives.

The study involved 34 Providers and 157 LGBTIPQQ people aged 23-55 years (47 TG, 25 L, 35 G, 50 B) in three cities, Nairobi, Kampala and Mbarara between 2015-2019. 

The 157 LGBTIPQQ respondents had been or were in a relationship for 6 months and above. This constituted eligibility. 

No, wait a minute. Is there a link between how one reacts to what one is provided with?

Six aspects were further investigated to show link between quality of life and Provider status and these were: sense of esteem; attributes of happiness or the happy gaze; propensity to seek lifespan or relationship counseling to understand/enjoy meaningful life; role of environment on gay relationships; and cultural sensitivity of Providers to gauge how Provider bias or affinity influences life improving seeking services.

And so? 

Providers introduced to cultural sensitivity trainings provided opportunities for KP to access them and this maintained a rapport. Providers were asked which extrinsic factor was more important: job security; welcoming communities; or accommodating parents. 17 Providers chose accommodating parents as the most important; 6 pointed out welcoming communities were the most important; and 11 highlighted job security. These Providers were involved in providing life-span guidance and counselling. So, it is clear that they were pointing toward a dependent and an independent stage of life. They affirmed that the environment has a profound influence on emotional growth which in turn affects the way a person engages in problem-posing and solving skills.

Power roles, status and gender expression are three pivotal in triggering or deterring IPV among LGBTIPQQ persons. When the victims cannot report the perpetrators because they fear losing a bread-winner or face, then it becomes complicated. But one way to address this anomaly is to empower the abused or vulnerable person with employable or money generating skills. E Pelled (2000), argues that “holding such abusive partners accountable motivates them to commit to their own and the partner’s well-being. Which under certain conditions, contributes to the healthier emotional fulfillment of both.” He continues to argue that “children who grow up in abusive situations, grow up terrorized, witnessing violence, become rigid and sometimes self destructing practices. Because they are exposed to negative or limited opportunities for role models, they end up with traumatic secrets. Examples of these traumas are constant fear, feeling loneliness, experience instability, discontinuity, are always moving and cannot get a foothold into economic independence.” Perceptions of non violence companionship improve wellbeing, sense of being and direction. This means that access to life saving information, education and communication ( IEC) is crucial.

Lamerial (2015) chronicles how “differences between feminine and masculine lesbian, gay, bisexual, transgender, queer (LGBTQ), self-reported victimization, perpetration, and acceptance of IPV. Results identified that masculine LGBTQ-identifying students reported higher levels of victimization, perpetration, and acceptance of violence, providing implications when assessing for risk and protective factors of same-sex IPV. 83% of LGBTQ adults reported suffering emotional abuse and coercion within their same-sex relationship; 32% of LGBTQ adults reported some form of physical abuse, and 52% experienced being threatened by their same-sex partner. Although high prevalence rates of same-sex IPV exists, little is known regarding the risk and protective factors of IPV.” 

He re-emphasizes the role of community in ensuring quality life. 

“Individual and relational development remains important, and healthy relationship patterns serve as a protective factor to violence in adult relationships due to the lack of role models displaying healthy relationship behaviors for LGBTQ-identifying individuals,” he asserts. When it comes to IPV, Transgender and Lesbians report more incidences than say Gay persons. This is what Lamerial (2015) in another study of who among Transgender, Lesbian and Gay are more likely to report IPV. “IPV victimization, perpetration, and related attitudinal differences exists between male and female LGBTQ. Study results found that females reported higher levels of psychological victimization than gay males. Additionally, the male participants reported greater attitudinal acceptance of IPV and a propensity for sadism. Counseling implications regarding IPV victimization, perpetration, and attitudinal acceptance for IPV among LGBTQ populations need to be one-shoe fits-all.” The need for interventions that are KP-led or ally-led and focused on improving health of KP increased a culture of dignity at individual, household and community levels. This is what Strickler (2015) argues when he asserts that “Lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) persons experience partner and other violence at high levels requiring culturally competent interventions.Focusing on LGBTQ experiences of violence, with intentions to collaborative or build networks with other organizations builds opportunities for experiencing fuller life by KP. It also provides opportunities for referral because different organizations would be involved in addressing sexual and partner violence, promoting LGBTQ community health and safety, and concerned with social inclusion and legal protection of LGBTQ individuals, families, and communities. These programs increase provider and community competency and capacity toward improving LGBTQ safety, health, and well-being.”

Can you tell us more? This gets interesting!

90 LGBTIPQQ respondents with median age 25 (IQR 23-45) claimed being well off was connected to access to services, admission to social spaces that improve life, freedom to associate, speech, movement, emotional growth, integrity, dignity affirmation, confidence and self care practices. Restricting the movement of others means that they cannot associate, exercise their autonomy, agency or engage in life preserving activities. 

Three FGDs of 15 members each in three cities were used to understand how emotional growth or maturity was connected to IPV. FGD A of 15 with median age 24 (IQR 22-45) cited regular or steady salary, going out, and relationship counseling were key in deterring aggressive practices, coping and dignity affirmation. 

FGD B of 15 members with median age 23 (IQR 23-45) reported that dependency and power status or the roles one played were a major role in deterring or fueling IPV events.

FGD C of 15 with median age 28 (IQR 23-49) with pensionable jobs, had health insurance and were openly gay reported that Providers who treated them with dignity encouraged them to engage in self care, errand-running, school retention up to when they gained qualifications and keep their jobs. They further pointed out that this set actualizing background compelled them to adhere to higher civic standards.

32 respondents with median age 30 (IQR 23-55) said they were happy and claimed it was due to five things: Spiritual growth, they attributed their happiness on being able to let their spirituality grow and thrive; chemistry/connecting with one another. This gave them confidence and trust; financial contentment, meant that even they earned little they could afford their lifestyle, spent or saved well; recreation, meant they engaged in a variety of community activities; compassionate and mutuality, meant they were invested in the relationship, were genuinely there for each other emotionally, financially and physically; and lastly, fidelity, was the ‘Holy Grail’ of relationships and it empowered them to agree on life preserving or safer practices and boundary setting.

35 respondents with median age 24 (IQR 23-29) had experienced IPV more than one time, reported they were deluded by grandeur, a partner had a sweet tongue and somehow they stayed. They were disappointed but preferred to be locked in abusive relationships than open up to Providers who may end up ridiculing them. 7 cited alcohol, drug and cigarette abuse. All regretted committing to the relationship but hoped things would change. Commitment remorse and avoidant coping is a common KP phenomena.

A Word To The Wise!

Relationships thrive on a continued effort to sustain investment in care, quality living, agreements of good conduct and creativity. Not delusions of grandeur, lies, appearances and pretending. This continued effort toward a goal is known as fidelity which by itself is the ‘Holy grail’ of relationships. Don’t take anything for granted but rather work harder toward thriving and happy lives.

It is like filling up one's car with fuel only to forget about coolant, water and oil. Or, forget to fill up air pressure in the wheels, and expect to run the car smoothly. Relationships start emotionally but they must be watered by the other requirements of the body. Relying on emotions may be a barrier to nurturing the structural side of relationships. This leads to a frustration domino. Poorly managed frustration breeds anger and depression. Poorly managed anger and depression breed general anxiety disorder (GAD). GAD in turn breeds aggression, which breeds self-abuse, depression and violent acts.

Conclusion:

The environment has a profound influence on emotional growth which in turn affects the way a person engages in problem-posing and solving skills. Providers empowered with cultural sensitivity trainings are more likely to motivate KP to take demand, take up and be retained in service delivery continuum. KP empowered to engage in fully experiencing their communities, thrive well and achieve quality life goals. They are able to explore meaning out of life. This opens many ways to understand people before  and if they identify a partner they have pointers to committing to long term relationships. Reading about or seeking relationship counseling is an important best practice. Age and status are crucial in understanding IPV. Identifying and measuring IPV makes it easier to provide interventions against its perpetration. Definitions or claims of being well off, should factor in attributes other than monetary or material. Emotional, biological and social services are as equally important a consideration. Finance and fidelity counseling services are an important intervention self esteem of KP is to be sustained. Further studies into life-span mentorship and guidance cultures led by KP will throw more light on positive coping skills. KP Providers who are culturally sensitive to KP-related provide quality services. When KP are willing to demand and access social support when in need and have the desire to improve on their lot, it sets in place a role model culture. It is an opportunity for self care, healing and thriving. 

For more, read Kampala Sexuality Journal. Find us at tweeter  @JournalKsj

Reference:

E Peled, Parenting by men who abuse women: issues and dilemmas, The British Journal of Social Work, Volume 30, Issue 1, February 2000, Pages 25–36, https://doi.org/10.1093/bjsw/30.1.25

Goodman, Lisa, and Deborah Epstein. “Refocusing on Women: A New Direction for Policy and Research on Intimate Partner Violence.” Journal of Interpersonal Violence, vol. 20, no. 4, Apr. 2005, pp. 479–487, doi:10.1177/0886260504267838.

Lamerial Jacobson, Andrew P. Daire & Eileen M. Abel (2015) Intimate Partner Violence: Implications for Counseling Self-Identified LGBTQ College Students Engaged in Same-Sex Relationships, Journal of LGBT Issues in Counseling, 9:2, 118-135, DOI: 10.1080/15538605.2015.1029203

Lamerial E. Jacobson, Andrew P. Daire, Eileen M. Abel & Glenn Lambie (2015) Gender Expression Differences in Same-Sex Intimate Partner Violence Victimization, Perpetration, and Attitudes among LGBTQ College Students, Journal of LGBT Issues in Counseling, 9:3, 199-216,DOI: 10.1080/15538605.2015.1068144

Rachel Jewkesa. “Intimate partner violence: causes and prevention.” The Lancet Vol. 359, Issue 9315, 20, April 2002, pp. 1423-1429, https://doi.org/10.1016/S0140-6736(02)08357-5

Wallerstein, J. S., & Kelly, J. B. (1976). The effects of parental divorce: Experiences of the child in later latency. American Journal of Orthopsychiatry, 46(2), 256-269.

http://dx.doi.org/10.1111/j.1939-0025.1976.tb00926.x

Strickler, Edward, Jr, MA, MA,M.P.H., C.H.E.S., and Quillin Drew. "Starting and Sustaining LGBTQ Antiviolence Programs in a Southern State." Partner Abuse, vol. 6, no. 1, 2015, pp. 78-106. ProQuest, https://stmarys-ca.idm.oclc.org/login?url=https://search.proquest.com/docview/1648967251?accountid=25334, doi:http://dx.doi.org/10.1891/1946-6560.6.1.78.