Adapting Evidence-Based Interventions to Reduce Alcohol and Concurrent HIV/STI Risk Behaviors Among Street Sex Workers in Mongolia

BACKGROUND & PURPOSE: Surrounded by countries experiencing HIV epidemics, Mongolia still has low HIV prevalence. However, a competing, growing constellation of structural factors suggest that without rapid intervention deployment, Mongolia may join the regional epidemic. These factors result from the economic transition since 1990 from a centrally planned to a free market economy, and devastating economic consequences leading to over 32% of the population living below the poverty line. There have been severe increases in survival sex work among women, homelessness, migration of workers within and through the country, and a deteriorating health and social services delivery system. Concurrent with escalating opportunities for risky heterosexual behaviors are mounting rates of alcoholism – particularly among sex workers- and sexually transmitted infections (STIs). Currently, reported HIV cases remain clustered within high-risk groups with 60% of reported female HIV cases detected among sex workers. The purpose of this study was to examine the efficacy of a combined sexual risk reduction and motivational interviewing intervention on reducing sexual risk among alcohol dependent women who exchange sex in Mongolia.

METHODS: The Women's Wellness study adapted and combined two interventions: a 4-session manualized HIV sexual risk reduction intervention (HIVSRR) and a 2-session manualized motivational interviewing (MI) Intervention and tailored them to alcohol-abusing women engaging in sexual risk behaviors in Mongolia. The study then tested these in a 3-arm randomized clinical trial with 166 female, street-based sex workers assigned to either the combination (HIVSRR+MI), a single(HIVSRR) risk reduction condition, or a time-matched wellness promotion control (WP-C) condition. Hypothesis testing was concerned with reductions in unprotected acts of vaginal and anal sex with paying partners. Face-to-face, computer-assisted interviews were conducted at immediate post-intervention, and 3, and 6 months post intervention.

RESULTS: One hundred and sixty-six women were enrolled and randomized to the study. Participants ranged in age from 18 to 40; most had never been married (67%) and most (67%) reported having dependent children under the age of 18, with whom they lived. Findings demonstrated reductions of unprotected sex and harmful alcohol use among sex workers across all conditions. For example, mean ratios for unprotected vaginal sex among paying partners decreased for all groups: from 35.3% to 14.3% for the Wellness group; from 27.6% to 3.2% for the HIVSRR group, and from 27.0% to 11.9% for HIVSRR+MI group. These reductions are statistically significant over time for each group, although the reduction differences between groups are not significant. Harmful alcohol use was also reduced significantly across all groups, but not between groups, sustained over 6 months.

CONCLUSIONS & IMPLICATIONS: Findings suggest that even low impact interventions, such as a Wellness condition, can yield considerable sexual risk and alcohol use reductions among these vulnerable women. Adaptation issues related to the implementation of motivational interviewing in Mongolia will be discussed, as will issues related to mediating factors which may explain why significant reductions were found across study conditions.