In pictures: Putting marginalized people at the heart of community-based contraceptive and HIV care

Client & healthcare provider

The Moonlight Star Clinic in Bwaise, Kampala provides integrated HIV and contraceptive care to the local urban community including sex workers, migrants, and young people. An initiative run by Reproductive Health Uganda (RHU), the clinic offers care through evening outreach sessions, which were introduced to accommodate clients’ work schedules, making healthcare more accessible and convenient. Clients are often referred to the evening clinic through a peer network system generating demand for access to this type of healthcare. Trained peer educators and community-based health providers work together with RHU nurses delivering integrated contraceptive and cervical cancer care, as well as sexually transmitted infections (STIs) and HIV testing and treatment, including access to antiretroviral treatment and pre-exposure prophylaxis (PrEP).

Providing access to stigma-free healthcare

RHU’s clinic in Bwaise

The Moonlight Star Clinic in Bwaise, Kampala, offers a stigma-free environment for clients located in the heart of their community. The clinics’ ethos is to ensure clients feel welcome and safe when accessing healthcare. With a flexible timetable, clients can visit in the evenings at their convenience and receive an integrated package of care including contraception as well as testing and treatment for STIs and HIV.

Treated with respect dignity

Joseline, sex worker

Joseline shares her experience of being exposed to STIs, often leading to infection, through fear of stigma and discrimination at some healthcare facilities.

“Before the RHU Moonlight clinic, other health facilities used to treat us badly. It was so hard to talk to the health workers because they didn’t respect our work, they would treat us like trash, most of us would just choose to stay with our STIs than endure that abuse. But RHU makes us feel free, we feel loved and valued here. They teach us rights, give us services and they give us treatment for free. COVID, however, has affected us a lot. People are not aware about how it is spread and because of the lockdown, services are hard to get."

Empowerment through contraceptive care

Doreen, sex worker 

Many sex workers face unplanned pregnancies through a lack of access to information and contraceptive care.

“Before RHU we had unplanned pregnancies and as a result, we now have children looking like our age since we gave birth when we were still young. We didn't have information even as simple as condom use. We didn't regard it as important. Now with RHU, people are now planning when and how many children to have because they are empowered with information and services are available."

Education and contraception reduce unplanned pregnancies

Barbra, sex worker

Barbra talks about women struggling with an unplanned pregnancy, and how in some desperate cases, resort to unsafe methods which can lead to serious health complications, injury, and even death.

“In my community women would just drink bleach or use sharp things like knives to get rid of unplanned pregnancies and many died or got hurt. We are thankful for RHU because now such cases are very rare. They have done a good job teaching us about using contraceptives and actually providing them to us with so much ease. The pandemic has cost us a lot, outreaches have been stopped because of the lockdown, so service delivery has decreased. But if RHU can train us and facilitate us, we are able to move to different hot spots and support our friends.”

Training sex workers to become peer educators within their community

Jackline, Healthcare provider

Within the sex worker community, the sengas (senior women, matrons, and mentors) are considered to be key influencers among their circles. Their experience and respectability led the RHU team to approach them and encourage them to train as peer educators so that they can share their knowledge of keeping safe and healthy and where to access contraceptive and STI care.

“Sengas understand the rules of the game and know who is who. We identify and train them as peer trainers so they can mobilize and educate fellow sex workers. This is because sex workers are a very protective and secretive community because of society’s stigma and prejudice, they fear to come out in the open. We equip peers with information, we give them peer education materials so that every time they are approached, they can share information.”

Peer educators support fellow sex workers to access care and treatment

Esther, sex worker

Esther talks about how her work as a peer educator has helped other nekos (a term short for ‘nekolela gyange’ meaning sex worker) to seek health care and treatment with confidence.

“RHU trained us as peer educators, we are helping our peers to come to the health facility so they don’t have unplanned pregnancies and end up taking bleach or pierce the stomach to remove the baby. Nekos are no longer hiding out of shame, they come easily to get treatment and services. Even neighbours no longer consider this [RHU] a clinic of prostitutes. Concerning the COVID pandemic, key populations like sex workers are very key in transferring infection because we meet very many people, we need information on how to protect ourselves. This is our job - we have to eat, teach us to be careful.”

Sex workers teach others about contraceptive care and STIs

RHU teaching session

The elders, also referred to as Sengas, are trained to teach other sex workers in their community about contraceptive care and how to avoid STIs and unplanned pregnancies. They also provide referral forms for their peers to attend the Moonlight Clinic.

Providing access to information and free STI care and treatment for young people

Robert, client 

Robert shares his experience of accessing STI care through the RHU clinic, which targets the local youth population who would normally struggle to access information and youth-friendly care.

“Before RHU, it was very hard for us to get information and services for STIs. Even the available health workers are very friendly and helpful. For example, during COVID, RHU had a project that was giving free services to young people between 16-19 years. This helped to prevent unplanned pregnancies and most young people got the much-needed services for the different STIs. They have also done a good job to teach young people and have encouraged usage of condoms.”

Photos ©IPPF/Fortunate Kagumaho/Uganda