The Republic of Uganda is one of the poorest countries in the world, with most poverty in rural areas. Uganda has a population of over 42 million, of which 8.5 million live in the capital Kampala. Uganda is a member of the East African Community (EAC) surrounded by Rwanda, Kenya, Tanzania, South Sudan and Congo. Despite the relatively high number of poor people, the economy has steadily grown since the 1990s. 

Uganda has been under colonial rule by the UK from 1894-1962. The official languages are English and Swahili. Since 1986 Uganda has been ruled by Yoweri Museveni, re-elected in January 2021. The opposition contested the election because of alleged fraud, and Human Rights Watch mentioned widespread violence and repression, including thousands of arrests and torture. 

Transparency International ranks Uganda as one of the most corrupt countries in the world. Corruption is manifested by grand-scale theft of public funds and petty corruption at all levels. Also, freedom of expression is violated consistently, according to Amnesty. 

Uganda is a transit country for drug trafficking. That happens by land, over the border, where there is less supervision (Busia, Bunagana), and the Entebbe airport, allegedly a 'major trafficking route’.

Uganda adopted a criminal justice approach to dealing with drug use, most recently reinforced through enacting the Narcotic Drugs and Psychotropic Substances (Control) Act 2015 (NDPSA), also known as the Narcotic Law. The Act strictly regulates the use of drugs. It imposes sentences for drug possession and use, which are substantially more severe than those previously provided under the National Drug Policy and Authority Act introduced in 1993. The Narcotics Law penalises possession of illicit drugs with prison sentences of up to 15 years. Trafficking is punishable with a life sentence. No comprehensive study on the laws and policies impacting people who use drugs has been undertaken. Very little information is also available on the new NDPSA and its implications for people who use drugs.  According to Uganda Harm Reduction Network, this Act introduces a ‘much more rigorous and criminal law based legal regime’ regarding drug use. It is in line with the international ‘war on drugs.’ The NDPSA adoption proceeded mainly without considering the human rights implications for people who use drugs.  

The Ugandan laws (sections 136, 137, 138 and 139 of the Penal Code Act) also criminalise sex work and consensual same-sex relationships. Same-sex relations are defined as “having carnal knowledge against the order of nature”, punishable with up to 10 years. Sex work is punishable with up to seven years imprisonment. Law enforcement officers routinely harass sex workers under the vagrancy offences of the Penal Code Act. The Registration of Persons Act 2015 does not recognise transgender individuals, which exposes them to be victimised under nuisance offences, among others.

The Non-Governmental Organizations (Amendment) Act (NGO Act), passed in 2016, has been a considerable barrier for NGOs in the country. Controversial registration procedures (requiring recommendations from government officials; annual re-registration), and the requirement that all foreign funds be passed through the Bank of Uganda, are among the things that limit the output of NGOs. Furthermore, civil society activities have been under stricter control since the introduction of the Public Order Management Bill, which gives the government the right to prohibit public assemblies.  

To meet the UNAIDS 90-90-90 and national 95-95-95 goals Uganda AIDS Commission (UAC) facilitated with partners the development of the National Key and Priority Populations Action Plan (2020/2021 – 2022/2023) to enable the scale-up of national Key and priority populations interventions. People who use drugs are mentioned as one of the Key Populations. 

The Action Plan was aligned with the National HIV Prevention Roadmap (2018-2030) and the National HIV and AIDS Strategic Plan (NSP) 2020/21 – 2024/25. The National HIV and AIDS Strategic Plan remains the primary source of information regarding the Ugandan government’s support of harm reduction interventions. However, the plan doesn’t highlight specific financing estimates towards harm reduction and specifically for particular groups other than broader programmatic statements.

The 2019 PEPFAR Country Operational Plan (COP19) for Uganda reflects another internationally funded effort towards epidemic control in line with the UNAIDS 90-90-90 goals.  

Also, in 2019 Uganda Guidelines for Prevention, Testing, Care and Treatment of Hepatitis B and C Virus Infection were published. 

Exact figures on the number of people using drugs in Uganda are unavailable. Size estimates for people who inject drugs range between 11,000-20,000 nationwide and between 621 and 3837 in the Kampala region. Size estimates for people who use drugs have not been conducted. With limited national studies done on drug use and harm reduction, there is a need for both size estimate studies and bio-behavioural studies.

According to a study conducted by Community Health Uganda in 2017, heroin (44.8%) and cocaine (16%) are the most injected drugs in Kampala and Mbale. Besides the use of heroin, cocaine and crystal meth, the following practices were mentioned by key informants that were also mentioned in reports or news articles: Smoking cannabis ('sada'), chewing khat (‘miraa’), and ‘sniffing jet fuel’. According to a rapid assessment of 125 people who inject drugs in 2019, 72% were using heroin.   

Cannabis is manufactured within Uganda, as is Khat (miraa). Cannabis is only allowed for medical use. Both cannabis and khat are illegal to grow or sell. Khat farmers try to lobby to decriminalise khat farming. A jet fuel sample taken by news reporters from The Monitor indicated that this 'jet fuel' wasn’t aviation fuel but Toluene (methylbenzene, toluol, phenylmethane): a chemical substance commonly used as an industrial solvent for manufacturing paints, chemicals, pharmaceuticals, and rubber. 

The Community Health Uganda study identified hotspots where people who inject drugs reside to buy and use drugs: 98 in Kampala and 31 in Mbale. According to an undercover investigation of the Matooke Republic, the neighbourhood Kisenyi is the most notorious hotspot, where migrants (Somali) and Ugandan youth reside to use drugs. AMICAALL et al. (2013) revealed that most drug use hotspots in Kampala are found in slums—Katwe, Wabigalo, Kivulu, Kisenyi, Bwaise, Kabalagala, Kimombaasa, Ndeeba, Kalerwe, Nateete, and Bakuli. Prisons in Uganda have also reported drug use (Uganda Prisons Services, 2009).

Makerere University Crane Surveys, funded by PEPFAR through CDC, found an HIV prevalence of 17% (higher for women at 24%) among their sample of 1172 people who use drugs —against the national prevalence of 6.2%. Hepatitis B prevalence was 20%. However, there is no national size estimate regarding infectious diseases among people who use drugs. TB remains the leading cause of death among people who use drugs living with HIV. A CDC-funded study is tracking the prevalence of HIV, hepatitis and treatment among key populations, according to a key informant.   

Uganda is one of the 30 high-burden HIV/TB countries. National HIV prevalence is estimated at 6.2% (5.8-6.7) among the adult population aged 15 – 49 years, translating to a total burden of HIV in Uganda of 1,299,391 in 2018, down from 1,500,000 in 2016 (MoH Spectrum Estimates, 2017). The MoH further estimated that the number of new infections in 2017 was approximately 52,813.  

Key populations most affected by HIV include sex workers, people who use and inject drugs, long-distance truck drivers, men who have sex with men, fisher folks, and uniformed forces. The criminalisation of sex work, social stigma, and homophobia exacerbate barriers for sex workers in Uganda to access health services and disclose their occupation to healthcare providers. This leads to avoidance of HIV testing and care. Male sex workers who have sex with men face heightened stigma and homophobic violence, which contributes to them being less inclined to seek HIV services and has a significant impact on their mental health. Other barriers to accessing HIV services by people who use drugs, sex workers and LGBTIQ members include lack of awareness around these KP's unique social and health issues by service providers, social stigma and negative attitudes; an inadequate number of health workers trained to provide tailored friendly services; service procedures and arrangements requiring partners to be tested together; shortage of needed services and commodities; limited service spread-out; inadequate equipment and infrastructure; budgeting and coordination issues as well as limited information about available services and limited statistics on the numbers and specific needs of these populations.

The total investment in harm reduction in Uganda is funded primarily by international partners and implemented by local partners. Both harm reduction and HIV and AIDS interventions in Uganda are highly donor-dependent. Funding for harm reduction increased from 201,317 USD in 2017 to 370,237 USD in 2019. This largely supported advocacy interventions for harm reduction, which resulted in including people who use drugs in the National HIV Strategic Plan. Furthermore, the Ministry of Health developed Harm Reduction Guidelines in 2019, which mention prevention, treatment and care, and psychosocial support. However, there is no national strategic plan for harm reduction, and It should be noted that the national HIV Strategic Plan does not highlight specific financing estimates towards harm reduction.

In Uganda, there is a considerable lack of harm reduction services for people who use drugs. There are private rehabs, but they are costly and inaccessible for most people who use drugs. Services for people who inject drugs, such as NSP and OAT were limited in scope and covered only two districts of Kampala and Wakiso.

The assessment on funding for harm reduction conducted by Harm Reduction International and UHRN recommends ‘embrace harm reduction as the overarching strategy to respond to drug-injecting related risks and harms’. Other recommendations are allocating more financial support, conducting a policy review to decriminalise drug use, and advocating for national mental health policy.

According to key informants, INPUD advises UHRN to build more evidence to convince the government to allocate funds for harm reduction. 

Since September 2020, there has been one OAT clinic in Uganda, located in Butabika Mental Hospital. UHRN screens and provides initial preparation, refers and links eligible OAT clients to Butabika National Referral Hospital and supports the continuation of psychosocial support services. There were 81 people who inject drugs enrolled on OAT in the period September – December 2020. Currently, there are 330-340 people enrolled in OAT, according to key informants. Because it is a pilot, the sustainability of the project is insecure. The OAT programme was possible through a PEPFAR investment of 300,000 USD and CDC technical assistance in collaboration with the Uganda Infectious Diseases Institute (IDI), the Ministry of Health, and Uganda Harm Reduction Network (UHRN). Other challenges include the distance and lack of funding to support transportation to/from the centre. Many people who want to enrol on OAT in Butabika are expected to transport themselves daily to access their daily doses but do not have the financial means. OAT uptake is low because of the lack of transport and the strict enrolment procedure (only limited to people who “inject”) as opposed to all groups of people using opioids.

UHRN has 4 regional offices with drop-in centres offering harm reduction services for people who use drugs. Among their services are HIV and hepatitis testing and referral, informing and preparing people who inject drugs for OAT, family support, naloxone distribution and NSP. 

NSP was planned to be piloted in 2016 in 4 regional hospitals, but due to a shortage of funds, only one hospital realised to offer NSP to 120 persons injecting drugs for 3 months. Because there were no funds for follow-up, the pilot could not continue. In 2019 UHRN obtained a small grant from Global Fund for NSP in 4 districts in Uganda, reaching 287 PWID with new clean needles and syringes together with tourniquets, cotton balls, swabs, water ampoules, condoms, lubricants and safe injecting IEC. This is still running, but funding post-2022 is insecure. Also, the scope of the NSP programme is far too small to reach all PWID. UHRN obtains funds from Rakai Health Sciences Program, Infectious Disease Institute, Mild may Uganda, OSIEA, FRONTLINE AIDS, NIH/ MSPH, ARASA, TASO, Harm Reduction International and Makerere Joint AIDS Program.

In Uganda there is not an established peer network, for example as there are through affiliate constructions with INPUD. Neighbouring countries Kenya and Tanzania do have national peer networks (KenPUD and TanPUD).  

However, organisations in Uganda that work with key populations such as Key Populations Uganda do have a good network among peers on organisational level and have paid peers in staff. Same for Uganda Harm Reduction Network, that has a former heroin user in coordinating position. According to key informant UHRN uses ‘peer to peer model on community activities, documenting human rights violations, offer paralegal support and community led advocacy.’ Because of their peer involvement, these organisations have a good understanding of the situation and needs of their target groups, and do peer led community mobilisation. 

Nonetheless their scope is limited and representation of peers on a national level could be considered minimal.

The introduction of the Narcotic Law from a human rights perspective has a potential negative impact on offering harm reduction services. With jail sentences of up to 15 years for possession, people who use drugs are not motivated to advocate for themselves. A representative of UHRN says: “By further criminalising drug use, this law pushes people into the shadows. People are afraid to talk and afraid to seek much-needed medical help because the government has now definitively positioned drug use as a justice issue rather than a health issue.”

HRAPF (Human Rights Awareness and Promotion Forum) publishes annual reports together with UHRN with the support of the Open Society Institute for Eastern Africa (OSIEA) on human rights violations regarding people who use drugs. In their 2020 report, 81 human rights violations regarding people who use drugs were recorded, ranging from arbitrary arrests and violation of the right to a hearing to cruel and degrading treatment. Uganda Police Force and  Local Defense Unit are responsible for most violations. 

On the service delivery level, the possession of needles has been used by police as evidence for arrest and to prosecute people who use drugs on multiple occasions, according to a key informant. Also, paralegals risk being arrested when they contact people who use drugs. 

HRAPF supported the Anti-Narcotics Department of the Uganda Police Force to develop regulations on the human rights-based enforcement of the Narcotic Drugs and Psychotropic Substances (Control) Act which was reviewed by the Ministry of Internal Affairs in two meetings, according to their annual report. HRAPF supported the Anti-Narcotics Department of the Uganda Police Force in developing draft Standard Operating Procedures (SOPs) for implementing the drug laws in Uganda. The draft SOPs were created and reviewed by 40 enforcement officers in a two-day consultative meeting. The SOPs were also reviewed by 17 members of CSOs working on Harm reduction, Ministry of Health technical staff, and representatives from the community of PWUIDs.

There are advocacy efforts done by UHRN to sensitise police district commanders. The relationship between UHRN and the police is relatively good in Kampala. However, due to high staff turnover within the police, this hasn’t had a significant impact yet. 

In recent years there have been increased illegal arrests of people who use drugs, and police raided most ghettos to implement and enforce COVID-19 restrictions. The delayed hearing of ongoing court cases for people who use drugs being held in prisons/confinement created a backlog of uncompleted cases resulting in people staying longer in detention centres.

According to the assessment of CHAU and UHRN, 73.6% of the people who inject drugs in the survey reported that police had stopped them during the past 12 months, and 64.8% had been arrested or detained by police. Up to 56.8% said they had ever been jailed for a drug-related offence. Almost half (48.8%) reported that police had beaten them in the preceding 12 months. Respondents from UHAI's baseline denounced being beaten, bribed and even sexually abused by police officers, mainly when found to be engaging in sex work or being a transgender person.  

HRAPF could give some legal support: the majority of actions taken by HRAPF to support PWUD in 2020 were legal support in arrests and court.

Regarding other key populations, there are severe human rights violations, according to Uganda's Key Populations. In 2020 community residents and police raided a Children of the Sun Foundation (COSF), a shelter for homeless LGBTQI. Police beat and arrested 23 adults, including shelter residents, and charged them with “a negligent act likely to spread infection of disease” and “disobedience of lawful orders.” Police detained twenty shelter residents for over six weeks without access to lawyers for allegedly disobeying Covid-19 restrictions. 

There are no harm reduction initiatives available within prisons in Uganda and the government does not support harm reduction services in prisons as they see drug use as a criminal matter and not a health issue. 

A rapid situation assessment in 2008 by the Uganda Prisons Service and United Nations Office on Drugs and Crime amongst a sample of 459 prisoners and 85 health workers in 34 prisons in Uganda showed that 12% per cent of the prisoners had ever used drugs while in Ugandan prisons. The most commonly used drugs were cigarettes, cannabis and khat. There was no report of injecting drug use during that assessment. However, an HIV behavioural survey conducted in Ugandan prisons in 2013 showed that 9.8% of the prisoners and 5.7% of the prison staff had ever used drugs. Among those who had used drugs, 29.9% reported having injected drugs, including cocaine, heroin and opium. Among prisoners who reported using injecting drugs, 49.2% reported sharing injection equipment. 

According to a rapid assessment by CHAU and UHRN on harm reduction and HIV prevention for PWID in Kampala and Mbale, sharing of needles and syringes while in police or prison detention was reported by 15.5% of those who had ever been detained by a drug-related offence. A higher proportion reported this in Mbale (23.5%) than in Kampala (13%). Whereas most of the syringes available on the market and in health facilities are single-use, people who inject drugs tweak the needles to be able to reuse them. 

In the National HIV plan, there is no data on HIV or harm reduction interventions for prisoners. There is a mention of implementing HIV services for prisoners, with the responsible party being the Ministry of Internal Affairs. Uganda Prisons Service (UPS) provides HIV prevention services within prison settings, targeting prisoners and staff. However, only a proportion of prison facilities (about 20%) have health units, and only 5% provide comprehensive HIV control services. Further, because homosexuality is against the law, providing services for HIV prevention among MSM in prison settings is not possible, as this would go against the law. 

Key populations, including people who inject drugs, men who have sex with men (MSM), and female sex workers, are disproportionately affected by the HIV epidemic. A size estimate on these KP in Kampala was conducted in 2017 (published in 2019), estimating people who inject drugs in Kampala at 3892 (3090-5126), MSM at 14,019, and female sex workers at 8848. On the national level, the most prevalent KP in Uganda is fisher folks (>730,000). Female sex workers and men who have sex with men sizes were estimated at 130,000 (50,744-210,849) and 22,000 (12,692-32,635), respectively.

Especially women who use drugs are more vulnerable to HIV, hepatitis, violence and abuse. A rapid assessment of 125 people who inject drugs showed that more females (21.7%) than males (13.7%) started injecting by 17 years of age. In this report, focus group discussions mention the rape of women who use drugs and men having power over women. 

In Mbale, it was reported that most women who inject drugs also do sex work. Similarly, some of the female sex workers in Kampala said that they do sex work to raise money for drugs. Also, the report mentions that women depend on men for getting their drugs and often don't have control over what or how much they take. 

According to Uhai's baseline, pregnant and breastfeeding women who use drugs cannot enrol in the Butabika Medication-Assisted Treatment (OAT) program. Women are requesting a review of this policy. They also face additional stigma and discrimination as women, experiencing denial of quality healthcare and being shamed when seeking sexual and reproductive health services. 

In Uganda, 77% of the population is considered youth. Uganda Key Populations created a digital app to reach marginalised youth. 

It is safe to say that in Uganda there is a huge stigma on key populations. Uganda introduced several laws in the last decade that reinforce this stigma, allow police enforcement to make arrests among key populations such as LGBTQI and people who use drugs and problematize access to health services. 

Besides the law, both religion and culture are not supportive of key populations. “People who use drugs and LGBTQI have almost nowhere to go when they are in need of support. Even health services are not safe to go to for these key populations,” says a key informant.  When asked by a health clinician how he contracted a sexually transmitted illness, he mentioned that it was ‘from his boyfriend’. “So you are gay?!” she replied with averse and showed him the door. The same accounts for people who use drugs. The first response is: “Why are you using drugs?”

Uganda Key Populations introduced through PEPFAR funding scorecards which with key populations could score the health accessibility of their service providers. Though it was a very successful project in which the servicer providers also got feedback on their service provisions, the project was only on a small scale. 

According to UHRN going on the street and raising your voice is ‘not smart’ in Uganda. They advised a strategy to lobby behind closed doors with police and government officials. 

Based on data gathered via desk research and key informants and on the extensive consultation done by UHAI's baseline in Uganda, we propose the following recommendations:

Advocacy & Policy Reform

• Advocate for the decriminalization of people who use drugs, sex workers and LGBTIQ individuals.

• Advocate for approving a National Mental Health Policy to support people who use drugs with mental health challenges.

• Advocate for implementing a hybrid funding model to cater to the intersectionality of people who use drugs and provide small funds directly to community-based organisations at both the community and national levels.

• Advocate for the government to review Monitoring & Evaluation tools to capture information on people who use drugs and engage in sex work and those from LGBTIQ+ communities.

• Advocate for the government to embrace the public health approach and allocate resources for comprehensive SRHR/HIV and harm reduction services.

• Advocate for a harmonised approach to addressing the needs of people who use drugs, sex workers and LGBTIQ+ communities.

• Scale up advocacy and coordination among CSOs and engage with public sectors and international partners to support harm reduction services.

• Fund organisations of people who use drugs outside Kampala. 

Community-Based Research and Assessments

• Support people who use drugs-led organisations to conduct national needs assessment and population size estimation studies, including specific subgroups like people who use drugs and engage in sex work and those from the LGBTIQ+ community

• Fund research or baseline studies on the impact of substance drug use and its interaction with hormones, particularly among transgender persons using hormones.

Harm Reduction Services

• Roll out Opioid Agonist Therapy (OAT) to nearby government facilities and open additional OAT clinics in different locations.

• Expand harm reduction interventions to include alternative services such as income generation. Primarily support OAT clients in starting their lives over again with income-generating activities and skills development.

• Fund psychosocial support and mental health interventions for people who use drugs, sex workers and the LGBTQI+ population.

• Decentralize drop-in centres to create demand for harm reduction and sexual reproductive health services in hot spots.

• Embrace harm reduction as an entry point and overarching strategy for responding to drug-related risks and harms

Capacity Building:

• Conduct orientation and awareness training for healthcare providers, policymakers, law enforcement, judiciary, and the general public on people who use drugs and the benefits of embracing harm reduction.

• Undertake continuous medical education to train and orient healthcare providers on people who use drugs and intersecting issues with sex workers and LGBTQI+.

• Develop a fundraising and business continuity strategy for harm reduction implementing partners to reduce donor dependency, including advocating for domestic funding.