Research That Matters (January 17 - 20, 2008)

Purpose: To conduct needs assessment to explore HIV risk behaviors, concurrent alcohol use, mental health needs, and services availability and accessibility among women engaged in street-based sex work in Mongolia. Mongolia is bordered by Russia and China: two countries experiencing rapidly expanding HIV epidemics. Mongolia is experiencing a rise in the factors associated with HIV epidemics in other parts of the world. These include internal and external migration, primarily among men in search of employment, and hard to employ women -- often unmarried and with child and adult dependents – who then engage in survival sex. Mounting rates of alcoholism and sexually transmitted infections (STIs), and strong evidence that unprotected sexual contact in the presence of STIs enhances the probability of HIV transmission, suggests that without urgently needed interventions Mongolia is poised to become a significant contributor to the regional HIV epidemic.

Methods: In May of 2005, 48 female clients from the National AIDS Foundation (NAF) HIV prevention program were recruited for study participation. All were supporting themselves and their dependents by exchanging sex for money. Two group interviews were conducted in the capital city of Ulaanbaatar (n=24), and two in Darhan Uul (n=24), a provincial city to the north. Each participant completed individual questionnaires assessing current alcohol use, concurrent HIV/STI risk behaviors, mental health needs, alcohol treatment accessibility, use and service needs.

Results: Participants ranged in age from 18 to 40 (m= 28 yrs). Most had never been married (67%) and most (67%) reported having dependent children under the age of 18, with whom they lived. Over 85% of participants scored 8 or above on the AUDIT, indicating hazardous or harmful alcohol use. Scores on the BSI depression subscale indicated 39% of women exceeded depression level norms. Seventy percent of the women reported using condoms inconsistently and 83% of the women reported using alcohol before engaging in sex with paying partners. Of these, 38% reported that they are less likely to use a condom with a paying partner after using alcohol. Only two women (4%) reported ever having been treated for an alcohol problem. Ninety-eight percent reported that if available, they would participate in alcohol use and mental health treatment, indicating a preference for individual counseling. Women requested help with alcohol use, depression, intimate and paying partner violence, police harassment, HIV/STI risk reduction, pregnancy prevention and parenting.

Implications: Women identified inadequate resources to provide needed risk reduction and alcohol treatment services in Mongolia. Innovative adaptation, introduction and testing of low cost, targeted, empirically-validated prevention interventions is needed to help prevent the proliferation of HIV in Mongolia, and to meet the service needs of this vulnerable population of women. These findings informed a recently- funded two year study (NIAAA) to adapt and test the feasibility and preliminary effectiveness of a theory-based HIV sexual risk reduction intervention (HIV-SRR) combined with motivational interviewing (MI) for women with alcohol abuse histories and who engage in high risk sexual behaviors in Mongolia.