The future of children of female sex workers in Rwanda: A call to address their risk and vulnerability to HIV infection

Dear Editor

Female sex workers (FSWs) are one of the populations most at risk for becoming infected with HIV in sub-Saharan Africa, a region with the worst disease burden globally. In Rwanda, there are an estimated 15,000 FSWs [1]. The HIV prevalence among FSWs in Rwanda was estimated to be approximately 46% in 2015. The 2015 Behavioral and Biological Surveillance Survey among female sex workers enrolled 1978 FSWs [2]. In this study, 4% and 10,4% of the FSWs in Kigali city and other provinces respectively were aged 15–19 [2]. Nearly a quarter (22%) reported conducting their business from home as opposed to other hotspots [2]. Participants largely (70%) reported that they had sexual intercourse for their first time at the age of 15–19 [2]. Among them, 43% were engaged in the sex work for the first time within the same age range with 5.5% reporting engaging in their first commercial sex under the age of 15 years [2]. Despite the progress made in HIV interventions amongst FSWs as evident by the decreased prevalence, little work has been done on their children, an equally vulnerable population.

The Joint United Nations Programme on HIV/AIDS (UNAIDS) defines sex work as the receipt of money or goods in exchange for sexual services, either regularly or occasionally. Sex work has been historically illegal in Rwanda. This meant identifying FSWs' children was difficult and thus increasing the children's vulnerability and marginalization. However, through civil society advocacy, Law Nº68/2018 of August 30, 2018 determining offences and penalties in general decriminalized sex work in Rwanda [3]. Despite this notable intervention, children of FSWs continue to face various vulnerabilities that include: separation from parents, sexual abuse, early sexual debut, low school enrolment, psychosocial issues arising from witnessing their mothers' sexual interactions with clients, and social marginalization [4]. There is also the likelihood that they are introduced to sex work as adolescents. This intergenerational transmission of risks has also been shown, for example, through the problems that children of sex workers face in succeeding at school due to issues such as discrimination on the part of teachers and classmates [5]. Compromised educational success is especially dangerous for the female children of FSWs, as it may continue the cycle of poor, uneducated women who engage in sex work to survive. Despite this, very little work has been done on children of FSWs in our setting, and to our knowledge, there is no published study that provides data on their HIV rates.

The health and welfare of FSWs' children should be prioritized. In conclusion, children born to FSWs in Rwanda are potentially at high risk for many serious and fatal health problems, including HIV. An analogy can be made with the enrollment into antiretroviral therapy among HIV positive children of HIV-positive FSWs enrolled in the 2015 behavioral and biological surveillance survey in Rwanda. The study revealed that almost half (48%) were not enrolled in ART [2]. This low engagement in HIV care and treatment services is an important public health problem that warrants urgent attention. The presence and magnitude of other health problems among these children are poorly understood. To address these issues, there is a need to partner with sex workers and sex worker organizations to fund and conduct research on the sexual and reproductive health of FSWs' children. Such studies could aid in the implementation of programs specifically for FSWs children at the local, national, regional, and global levels. Development and implementation of family centered interventions to address FSWs’ children welfare should be informed by research findings.