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Self-Reported Adherence to Antiretroviral Therapy (ART) Among Women Engaged in Commercial Sex Work in Southern Uganda


We examined the correlates of self-reported adherence to antiretroviral therapy (ART) among women engaged in commercial sex work (WESW) in Uganda. We used baseline data from a longitudinal study, which recruited 542 WESW in Southern Uganda. We used nested regression models to determine the individual and family, and economic level correlates of self-reported adherence. Study findings show that older age (OR = 1.07, 95% CI = 1.013, 1.139), secondary education (OR = 2.01, 95% CI = 1.306, 3.084), large household size (OR = 1.08, 95% CI = 1.020, 1.136), high family cohesion (OR = 1.06, 95% CI = 1.052, 1.065), and high financial self-efficacy (OR = 1.07, 95% CI = 1.006, 1.130) were associated with good self-reported adherence to ART. Married women (OR=-0.39, 95% CI = 0.197, 0.774), depression (OR = 0.85, 95% CI = 0.744, 0.969), alcohol use (OR = 0.72, 95% CI = 0.548, 0.954), ever been arrested (OR = 0.58, 95% CI = 0.341, 0.997), and high household assets ownership (OR = 0.48, 95% CI = 0.313, 0.724) were associated with poor self-reported adherence to ART. Findings suggest a need to adopt a multi-level approach to address gaps in ART adherence among WESW.

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Data Availability

Due to the sensitivity around the data, the data will not be deposited in a data repository. However, data used in this analysis is available upon reasonable request. The team is open to data sharing provided the points outlined below, which were part of the study protocol, data sharing plan, and consenting process, are met; (1) A formal research question is specified a priori; (2) Names, affiliations, and roles of any other individuals who will access the shared data; 3) The deliverable(s)—e.g., manuscript, conference presentation—are specified a priori; 4)Proper credit and attribution—e.g., authorship, co-authorship, and order—for each deliverable are specified a priori; 5) A statement indicating an understanding that the data cannot be further shared with any additional individual(s) or parties without the PI’s permission; 6) IRB approval for the use of the data (or documentation that IRB has determined the research is exempt).

Code Availability

Statistical analysis code is available at the request of the first author.


  1. UNAIDS. UNAIDS data 2021.

  2. Karim SSA, Baxter C. HIV incidence rates in adolescent girls and young women in sub-Saharan Africa. The Lancet Global Health [Internet]. 2019;7(11):e1470–1. Available from:

  3. Lancaster KE, Cernigliaro D, Zulliger R, Fleming PF, Hill C, Carolina N, et al. HIV care and treatment experiences among female sex workers living with HIV in sub-Saharan Africa: A systematic review. Afr J AIDS Res. 2016;15(4):377–86.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Shava E, Manyake K, Mdluli C, Maribe K, Monnapula N, Nkomo B, et al. Acceptability of oral HIV self-testing among female sex workers in Gaborone, Botswana. PLoS ONE. 2020;15(7 July):1–12.

    Google Scholar 

  5. UNAIDS. 2020 Uganda HIV -AIDS fact sheet, 6th Sept 2021. 2020.

  6. Uganda AIDSC. Uganda Population Based HIV Impact Assessment. Uphia [Internet]. 2017;(August 2017):62–5. Available from:

  7. Mountain E, Mishra S, Vickerman P, Pickles M, Gilks C, Boily MC. Antiretroviral therapy uptake, attrition, adherence and outcomes among hiv-infected female sex workers: A systematic review and meta-analysis. PLoS ONE. 2014;9(9).

  8. Taylor G. Rolling out HIV antiretroviral therapy in sub-Saharan Africa: 2003–2017. Can Commun Dis Rep. 2018;44(2):68–70.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Kennedy S, Goggin K, Nollen N. Adherence to HIV medications: Utility of the theory of self-determination. Cogn Therapy Res. 2004;28(5):611–28.

    Article  Google Scholar 

  10. Palumbo PJ, Zhang Y, Clarke W, Breaud A, Sivay M, Cummings V, et al. Uptake of antiretroviral treatment and viral suppression among men who have sex with men and transgender women in sub-Saharan Africa in an observational cohort study: HPTN 075. International Journal of Infectious Diseases [Internet]. 2021;104:465–70. Available from:

  11. UNAIDS (Joint United Nations Programme on HIV/AIDS). Access to Antiretroviral Therapy in Africa, 2013. Status report on progress towards the 2015 targets [Internet]. 2013;1–10. Available from:

  12. Doshi RH, Sande E, Ogwal M, Kiyingi H, McIntyre A, Kusiima J, et al. Progress toward UNAIDS 90-90-90 targets: A respondent-driven survey among female sex workers in Kampala, Uganda. PLoS ONE. 2018;13(9):1–14.

    Article  Google Scholar 

  13. Dunkle KL, Beksinska ME, Rees VH, Ballard RC, Htun Y, Wilson ML. Risk factors for HIV infection among sex workers in Johannesburg, South Africa. Int J STD AIDS. 2005;16(3):256–61.

    Article  CAS  PubMed  Google Scholar 

  14. Alexander C. Tsai. and ASV. Syndemics and health disparities: a methodological note. Physiol Behav. 2017;176(3):139–48.

    Google Scholar 

  15. Allam RR, Takamiya M, Pant R, Gandham S, Yeldandi V, Thomas J, et al. Factors associated with non-adherence to antiretroviral therapy among female sex workers living with HIV in Hyderabad, India. Int J STD AIDS. 2020;31(8):735–46.

    Article  CAS  PubMed  Google Scholar 

  16. Baral S, Logie CH, Grosso A, Wirtz AL, Beyrer C. Modified social ecological model: A tool to guide the assessment of the risks and risk contexts of HIV epidemics. BMC Public Health. 2013;13(1).

  17. Wanyenze RK, Musinguzi G, Kiguli J, Nuwaha F, Mujisha G, Musinguzi J, et al. “when they know that you are a sex worker, you will be the last person to be treated”: Perceptions and experiences of female sex workers in accessing HIV services in Uganda. BMC International Health and Human Rights. 2017 May 5;17(1).

  18. Glick JL, Russo RG, Huang AKH, Jivapong B, Ramasamy V, Rosman LM, et al. ART uptake and adherence among female sex workers (FSW) globally: A scoping review. Vol. 17. Global Public Health: Routledge; 2022. pp. 254–84.

    Google Scholar 

  19. Shannon K, Strathdee SA, Goldenberg SM, Duff P, Mwangi P, Rusakova M, et al. Global epidemiology of HIV among female sex workers: Influence of structural determinants. The Lancet. 2015;385(9962):55–71.

    Article  Google Scholar 

  20. Namale G, Kamacooko O, Bagiire D, Mayanja Y, Abaasa A, Kilembe W, et al. Sustained virological response and drug resistance among female sex workers living with HIV on antiretroviral therapy in Kampala, Uganda: A cross-sectional study. Sexually Transmitted Infections. 2019 Sep 1;95(6):405–11.

  21. Long JE, Richardson BA, Wanje G, Wilson KS, Shafi J, Mandaliya K, et al. Alcohol use and viral suppression in HIV-positive Kenyan female sex workers on antiretroviral therapy. PLoS ONE [Internet]. 2020 Nov 1 [cited 2022 Jul 16];15(11). Available from:

  22. Kerrigan D, Karver TS, Muraleetharan O, Savage V, Mbwambo J, Donastorg Y, et al. “A dream come true”: Perspectives on long-acting injectable antiretroviral therapy among female sex workers living with HIV from the Dominican Republic and Tanzania. PLOS ONE [Internet]. 2020 Jun 1 [cited 2022 Jul 16];15(6):e0234666. Available from:

  23. Dyson YD, Mobley Y, Harris G, Randolph SD. Using the Social-Ecological Model of HIV Prevention to Explore HIV Testing Behaviors of Young Black College Women. Journal of the Association of Nurses in AIDS Care. 2018 Jan 1;29(1):53–9.

  24. Berben L, Dobbels F, Engberg S, Hill MN, de Geest S. An Ecological Perspective on Medication Adherence. West J Nurs Res. 2012 Aug;34(5):635–53.

    Article  PubMed  Google Scholar 

  25. Mitchell E, Hakim A, Nosi S, Kupul M, Boli-Neo R, Aeno H, et al. A socio-ecological analysis of factors influencing HIV treatment initiation and adherence among key populations in Papua New Guinea. BMC Public Health. 2021 Dec 1;21(1).

  26. Ssewamala FM, Sensoy Bahar O, Tozan Y, Nabunya P, Mayo-Wilson LJ, Kiyingi J, et al. A combination intervention addressing sexual risk-taking behaviors among vulnerable women in Uganda: Study protocol for a cluster randomized clinical trial. BMC Women’s Health. 2019;19(1).

  27. Tsai LC, Witte SS, Aira T, Altantsetseg B, Riedel M. Piloting a savings-led microfinance intervention with women engaging in sex work in Mongolia: Further innovation for HIV risk reduction. Open Women’s Health Journal. 2011;5(1):26–32.

    Article  PubMed  Google Scholar 

  28. Mergenova G, El-Bassel N, McCrimmon T, Terlikbayeva A, Primbetova S, Riedel M, et al. Project Nova: A Combination HIV Prevention and Microfinance Intervention for Women Who Engage in Sex Work and Use Drugs in Kazakhstan. AIDS and Behavior [Internet]. 2019;23(1). Available from:

  29. Witte SS, Aira T, Tsai LC, Riedel M, Offringa R, Chang M, et al. Efficacy of a savings-led microfinance intervention to reduce sexual risk for HIV among women engaged in sex work: A randomized clinical trial. Am J Public Health. 2015;105(3):e95–102.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Ssewamala FM, Byansi W, Bahar OS, Nabunya P, Neilands TB, Mellins C, et al. Suubi + Adherence study protocol: A family economic empowerment intervention addressing HIV treatment adherence for perinatally infected adolescents. Contemp Clin Trials Commun [Internet]. 2019 Dec 1 [cited 2022 Jul 18];16. Available from:

  31. Wilson IB, Tie Y, Padilla M, Rogers WH, Beer L. Performance of a short, self-report adherence scale in a probability sample of persons using HIV antiretroviral therapy in the United States. AIDS. 2020 Dec 1;34(15):2239–47.

  32. Wilson IB, Fowler FJ, Cosenza CA, Michaud J, Bentkover J, Rana A, et al. Cognitive and Field Testing of a New Set of Medication Adherence Self-Report Items for HIV Care. AIDS Behav. 2014;18(12):2349–58.

    Article  PubMed  Google Scholar 

  33. Prevention HIv, Prep A, Care HI v, Models SD, Charts D. NUTRITION CONSOLIDATED GUIDELINES FOR PREVENTION AND TREATMENT HIV Prevention and Diagnosis. 2020.

  34. Michaels E. Let patients see their medical records, Ontario college says. Vol. 141, Cmaj. 1989. 1077–1079 p.

  35. Skinner H, Steinhauer P, Sitarenios G. Family assessment measure (FAM) and process model of family functioning. J Family Therapy. 2000;22(2):190–210.

    Article  Google Scholar 

  36. Derogatis LR, Melisaratos N. The Brief Symptom Inventory: an introductory report The Brief Symptom Inventory : an introductory report. CambridgeOrg [Internet]. 2012;(July 2009):595–605. Available from:

  37. Lang AJ, Stein MB. An abbreviated PTSD checklist for use as a screening instrument in primary care. Behav Res Ther. 2005;43(5):585–94.

    Article  PubMed  Google Scholar 

  38. Bermudez LG, Jennings L, Ssewamala FM, Nabunya P, Mellins C, McKay M. Equity in adherence to antiretroviral therapy among economically vulnerable adolescents living with HIV in Uganda. AIDS Care [Internet]. 2016 May 5 [cited 2022 Jul 20];28(sup2):83. Available from:

  39. Weaver TL, Sanders CK, Campbell CL, Schnabel M. Development and preliminary psychometric evaluation of the domestic violence-related financial issues scale (DV-FI). J interpers Violence. 2009;24(4):569–85.

    Article  PubMed  Google Scholar 

  40. Benning L, Mantsios A, Kerrigan D, Coleman JS, Golub E, Blackstock O, et al. Examining adherence barriers among women with HIV to tailor outreach for long-acting injectable antiretroviral therapy. BMC Women’s Health. 2020;20(1):1–11.

    Article  Google Scholar 

  41. Ghidei L, Simone MJ, Salow MJ, Zimmerman KM, Paquin AM, Skarf LM, et al. Aging, antiretrovirals, and adherence: A meta analysis of adherence among older hiv-infected individuals. Drugs Aging. 2013;30(10):809–19.

    Article  PubMed  Google Scholar 

  42. Dorcélus L, Bernard J, Georgery C, Vanessa C. Factors associated with antiretroviral therapy adherence among people living with HIV in Haiti: a cross-sectional study. AIDS Research and Therapy [Internet]. 2021;18(1):1–9. Available from:

  43. Schatz NSGFJSEJBNJN. Comparison of Antiretroviral Therapy Adherence Among HIVInfected.pdf. 2019. p. 1177–1189.

  44. Goldenberg SM, Montaner J, Duff P, Nguyen P, Dobrer S, Guillemi S, et al. Structural Barriers to Antiretroviral Therapy Among Sex Workers Living with HIV: Findings of a Longitudinal Study in Vancouver, Canada. AIDS Behav. 2016;20(5):977–86.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Ghidei L, Simone MJ, Salow MJ, Zimmerman KM, Paquin AM, Skarf LM, et al. Aging, antiretrovirals, and adherence: a meta analysis of adherence among older HIV-infected individuals. Drugs Aging [Internet]. 2013 Oct [cited 2022 Jul 18];30(10):809–19. Available from:

  46. Allam RR, Takamiya M, Pant R, Gandham S, Yeldandi V, Thomas J, et al. Factors associated with non-adherence to antiretroviral therapy among female sex workers living with HIV in Hyderabad, India. International Journal of STD and AIDS. 2020 Jul 1;31(8):735–46.

  47. Clark DO. Age, Socioeconomic Status, and Exercise Self-Efficacy [Internet]. Vol. 36, The Gerontologist. 1996. Available from:

  48. Hegazi A, Bailey RL, Ahadzie B, Alabi A, Peterson K. Literacy, education and adherence to antiretroviral therapy in the Gambia. AIDS Care - Psychological and Socio-Medical Aspects of AIDS/HIV. 2010;22(11):pp. 1340–5.

  49. Long JE, Richardson BA, Wanje G, Wilson KS, Shafi J, Mandaliya K, et al. Alcohol use and viral suppression in HIVpositive Kenyan female sex workers on antiretroviral therapy. PLoS ONE. 2020;15(11 November):1–12.

    Google Scholar 

  50. Goujard C, Bernard N, Sohier N, Peyramond D, Lançon F, Chwalow J, et al. Impact of a patient education program on adherence to HIV medication: a randomized clinical trial. J Acquir Immune Defic Syndr [Internet]. 2003 Oct 1 [cited 2022 Jul 15];34(2):191–4. Available from:

  51. Dessie G, Wagnew F, Mulugeta H, Amare D, Jara D, Leshargie CT, et al. The effect of disclosure on adherence to antiretroviral therapy among adults living with HIV in Ethiopia: A systematic review and meta-analysis. Vol. 19, BMC Infectious Diseases. BioMed Central Ltd.; 2019.

  52. Naigino R, Makumbi F, Mukose A, Buregyeya E, Arinaitwe J, Musinguzi J, et al. HIV status disclosure and associated outcomes among pregnant women enrolled in antiretroviral therapy in Uganda: A mixed methods study. Reproductive Health [Internet]. 2017 Aug 30 [cited 2022 Jul 15];14(1):1–11. Available from:

  53. Andini S, Yona S, Waluyo A. Self-efficacy, depression, and adherence to antiretroviral therapy (ART) among Indonesian women with HIV. Enfermería Clínica [Internet]. 2019 Sep 1 [cited 2022 Jul 15];29:687–90. Available from:

  54. Carney B, Daniels C, Xu X, Sunil T, Ganesan A, Blaylock JM, et al. Association between depression and HIV treatment outcomes in a US military population with HIV infection. AIDS Research and Therapy [Internet]. 2021 Dec 1 [cited 2022 Jul 15];18(1):1–6. Available from:

  55. Uthman OA, Magidson JF, Safren SA, Nachega JB. Depression and adherence to antiretroviral therapy in low-, middle- and high-income countries: a systematic review and meta-analysis. Curr HIV/AIDS Rep [Internet]. 2014 Sep 1 [cited 2022 Jul 15];11(3):291. Available from:

  56. Kerrigan D, Karver TS, Barrington C, Donastorg Y, Perez M, Gomez H, et al. Mindfulness, Mental Health and HIV Outcomes Among Female Sex Workers in the Dominican Republic and Tanzania. AIDS Behav. 2021;25(9):2941–50.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Carmen HL, Natania M, Ying W, Angela K, Patricia O, Uzma A, et al. A longitudinal study of associations between HIV-related stigma, recent violence and depression among women living with HIV in a Canadian cohort study. Journal of the International AIDS Society. 2019.

  58. Ma H, Loke AY. A qualitative study into female sex workers’ experience of stigma in the health care setting in Hong Kong. International Journal for Equity in Health. 2019 Nov 14;18(1).

  59. Yeo EJ, Hlongwane K, Otwombe K, Hopkins KL, Variava E, Martinson N, et al. Key risk factors for substance use among female sex workers in Soweto and Klerksdorp, South Africa: A cross-sectional study. PLOS ONE [Internet]. 2022 Jan 1 [cited 2022 Jul 15];17(1):e0261855. Available from:

  60. Jewkes R, Milovanovic M, Otwombe K, Chirwa E, Hlongwane K, Hill N, et al. Intersections of Sex Work, Mental Ill-Health, IPV and Other Violence Experienced by Female Sex Workers: Findings from a Cross-Sectional Community-Centric National Study in South Africa. International Journal of Environmental Research and Public Health [Internet]. 2021 Nov 1 [cited 2022 Jul 15];18(22). Available from: /pmc/articles/PMC8620578/.

  61. Lancaster KE, Lungu T, Mmodzi P, Hosseinipour MC, Chadwick K, Powers KA, et al. The association between substance use and sub-optimal HIV treatment engagement among HIV-infected female sex workers in Lilongwe, Malawi. AIDS Care - Psychological and Socio-Medical Aspects of AIDS/HIV. 2017;29(2):pp. 197–203.

  62. Azar MM, Springer SA, Meyer JP, Altice FL. A systematic review of the impact of alcohol use disorders on HIV treatment outcomes, adherence to antiretroviral therapy and health care utilization. Drug and Alcohol Dependence [Internet]. 2010;112(3):178–93. Available from:

  63. Kalichman SC, Grebler T, Amaral CM, McNerney M, White D, Kalichman MO, et al. Viral Suppression and Antiretroviral Medication Adherence Among Alcohol Using HIV-Positive Adults. Int J Behav Med. 2014;21(5):811–20.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Milloy MJ, Montaner JSG, Wood E. Incarceration of people living with HIV/AIDS: Implications for Treatment-As-Prevention. Curr HIV/AIDS Rep [Internet]. 2014 Sep 1 [cited 2022 Jul 15];11(3):308. Available from:

  65. Damulira C, Mukasa MN, Byansi W, Nabunya P, Kivumbi A, Namatovu P, et al. Examining the relationship of social support and family cohesion on ART adherence among HIV-positive adolescents in southern Uganda: baseline findings. Vulnerable Child Youth Stud [Internet]. 2019 Apr 3 [cited 2022 Jul 18];14(2):181–90. Available from:

  66. Nabunya P, Bahar OS, Chen B, Dvalishvili D, Damulira C, Ssewamala FM. The role of family factors in antiretroviral therapy (ART) adherence self-efficacy among HIV-infected adolescents in southern Uganda. BMC Public Health [Internet]. 2020 Mar 17 [cited 2022 Jul 18];20(1). Available from:

  67. Nozipho Becker, Cordeiro LS, Poudel KC, Sibiya TE, Sayer AG, Sibeko LN. Individual, household, and community level barriers to ART adherence among women in rural Eswatini. 2020;1–20. Available from:

  68. Amiya RM, Poudel-tandukar K. Perceived Family Support and Antiretroviral Adherence in HIV-Positive Individuals: Results from a Positive Living With HIV Study. 2015.

  69. Melchiorre MG, Chiatti C, Lamura G, Torres-Gonzales F, Stankunas M, Lindert J, et al. Social Support, Socio-Economic Status, Health and Abuse among Older People in Seven European Countries. PLoS ONE. 2013 Jan 30;8(1).

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We are grateful to WESW in Southern Uganda, who agreed to participate in the study; this work could not be possible without them. Special thanks to the International Centre for Child Health and Development (ICHAD) at the Masaka Field Office, who coordinated the study in Uganda with study partners, Rakai Health Sciences Program and Reach the Youth Uganda. Lastly, to the research teams at Washington University in St. Louis, Columbia University in New York, University of North Carolina, Chapel Hill, and New York University. Kyaterekera study is funded by the National Institute of Mental Health (NIMH) under award number R01MH116768 (MPIs: Fred M. Ssewamala, PhD & Susan Witte, PhD). NIMH was not involved in the study design, data collection, analysis, findings interpretation and manuscript preparation. The content in this article does not reflect the views of NIMH or the National Institutes of Health.


The National Institute of Mental Health (NIMH), under award number R01MH116768 funds Kyaterekera study (MPIs: Fred M. Ssewamala, PhD & Susan Witte, PhD).

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FMS and SSW, conceptualized, received funding for the study and led and supervised all aspects of study implementation. PN, FMS and JK conceptualized the study. JK drafted the first manuscript and conducted data analysis. PN, SK, JN, OSB, LJMW, JN, NM, YT, SSW and FMS critically reviewed and contributed to manuscript revisions. EN and FN supervised data collection in the field. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Fred M. Ssewamala.

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The Institutional Review Boards of Washington University in St. Louis (#201811106), Columbia University Institutional Review Board (AAAR9804), Uganda Virus Research Institute Ethics Committee (GC/127/18/10/690) and Uganda National Council for Science and Technology (UNCST –SS4828) approved this study.

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Kiyingi, J., Nabunya, P., Kizito, S. et al. Self-Reported Adherence to Antiretroviral Therapy (ART) Among Women Engaged in Commercial Sex Work in Southern Uganda. AIDS Behav 27, 1004–1012 (2023).

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