Objective Our study aimed to determine the prevalence and correlates of sexually transmitted infections (STIs) among adolescent girls and young women (AGYW) employed as household domestic workers in Kampala, Uganda.

Methods Ugandan AGYW aged 14-24 participated in a community-based cross-sectional study in the Kampala Metropolitan Area from November 2023 to March 2024. Self-collected vaginal swabs were tested for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) using GeneXpert™. Testing for HIV and syphilis was performed using the Bioline™ HIV/syphilis Duo test. Correlates of STI prevalence were determined using modified Poisson regression.

Results Of 262 AGYW enrolled, the median age was 20 years (IQR 18-23), and 87 (33%) had an STI: Chlamydia trachomatis (27.5%), syphilis (5.7%), HIV (4.6%), and Neisseria gonorrhoea (1.5%). Overall, 14.9% had >1 STI. Of 12 AGYW with HIV, three (25%) were newly diagnosed, and 6/9 had detectable viral loads (≥1000 copies/ml). In the prior 12 months, 126 (48%) had received syndromic STI treatment, but only 35 (28%) notified their partners. Additionally, 102 (39%) had used emergency contraception, with 54% believing it was protective against STIs, including HIV. Factors associated with STI prevalence included receipt of non-cash (instead of salary) remuneration for domestic work (adjusted prevalence ratio [aPR] 2.26; 95% CI:1.04-4.92; P=0.040), lower education attainment (aPR 1.73; 95% CI: 1.16-2.57; P=0.007), alcohol consumption in past six months (aPR 1.72; 95% CI: 1.12-2.64; P=0.013) and transactional sex during the past six months (aPR 1.43; 95% CI: 1.01-2.04; P=0.045). Conversely, self-reported sexual abuse was negatively associated with STIs (aPR 0.48; 95% CI: 0.28-0.83; P=0.008).

Conclusion The high prevalence of undiagnosed STIs and unsuppressed HIV among AGYW domestic workers in Kampala highlights the urgent need to increase HIV/STI prevention, testing and treatment coverage for these underserved and vulnerable young women. Targeted interventions are needed to mitigate STI/HIV acquisition in this population.

What is already known on this topic - summarise the state of scientific knowledge on this subject before you did your study, and why this study needed to be done. Adolescent girls and young women (AGYW) in Uganda who are out of school and employed in household domestic work are a highly vulnerable population, often migrating from rural communities to cities with consequent social isolation, and are subject to unequal power dynamics with employers. This puts them at risk of intergenerational and transactional sex. The prevalence of STIs and HIV, and the associated socio-behavioural factors, have been poorly studied in this demographic, limiting the development of interventions for this group.

What this study adds - summarise what we now know as a result of this study that we did not know before. This cross-sectional study, which estimated STI and HIV prevalence among young females employed in household domestic work, found that one-third of AGYW domestic workers were diagnosed with at least one STI. The findings reveal a high burden of STIs and HIV, with many experiencing co-infections. Contributing factors such as poor working conditions, limited educational attainment and prevalent sexual behaviours associated with STIs– including transactional sex, sexual abuse, alcohol use, and inconsistent condom use– exacerbate their vulnerability.

How this study might affect research, practice, or policy - summarise the implications of this study. This research provides insights into STI and HIV risks for vulnerable AGYW employed in domestic work. It highlights the need for tailored HIV and STI interventions that focus on increased awareness, economic and educational empowerment, improved working conditions, socio-behavioural changes, legal redress, as well as expanded access to STI/HIV testing and treatment services for this hard-to-reach population.

The authors have declared no competing interest.

Research reported in this publication was supported by the Fogarty International Centre of the National Institutes of Health under award number D43TW009771 HIV and co-infections (MPI: Kambugu, Castelnuovo, Manabe) and partially through the National Institute of Biomedical Imaging and Bioengineering of the National Institutes of Health under Award Number U54EB007958 (YCM). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Ethics committee of Makerere University School of public health (MaKSPH-REC-262) gave ethical approval for this work

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↵* Shared last authorship

Alternate Contact: Barbara Castelnuovo, PhD, Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O. Box 22418, Kampala, Uganda bcastelnuovoidi.co.ug