“It’s worse with fellow patients… they judge you as evil”:  Barriers to access and utilisation of HIV/STIs prevention and care services among trans-women sex workers in the greater Kampala metropolitan area, Uganda.

Abstract

<jats:title>Abstract</jats:title> <jats:p>Background Trans-women sex workers bear the greatest brunt of HIV and other sexually transmitted infections (STI). Trans-women are 49 times more at risk of HIV infections compared to the general population. However, they remain underserved and continue to grapple with challenges in access to and utilisation of HIV/STI prevention services. Our study explored the barriers to access and utilisation of HIV/STI prevention services and associated coping mechanisms. Methodology This exploratory qualitative study was conducted among trans-women sex workers in the Greater Kampala Metropolitan area, Uganda. Twenty-two in-depth interviews, six key informant interviews and nine focus group discussions were conducted to obtain data on barriers to access and utilisation of HIV and other STI prevention and care services, and coping strategies of trans-women sex workers. Data were analysed through thematic analysis under a hybrid of inductive and deductive approaches. Results Barriers to access and utilisation of HIV/STI prevention and care services were classified as individual, community and health system barriers. Individual barriers included internalised stigma and low socio-economic status. Health system barriers included discrimination by some healthcare providers, stigmatisation by fellow patients, stockout of lubricants drugs and other medical supplies, inadequate access to trans-specific STI drugs, and high cost of drugs. Community barriers comprised social exclusion and lack of recognition by other key population groups, and transphobia. The coping strategies included the use of substitutes such as lotions, avocado, egg white or yoghurt to cope with a lack of lubricants. Herbs were used as substitutes for STI drugs, while psychoactive substances were used to cope with stigma and discrimination, and changing the dress code to mimic gender identity. Conclusion Trans-women sex workers grapple with access to HIV/STI prevention and care services. Individual, community and healthcare facility level barriers hindered trans-women sex workers from access and utilisation of HIV/STI prevention and care services. There is a need to create an enabling environment in order to enhance access to and utilisation of HIV/STI prevention and care services for trans-women sex workers through sensitisation of healthcare providers, other key population groups and the community on the transgender identity.</jats:p>