Efficacy of a Savings-Led Microfinance Intervention to Reduce Sexual Risk for HIV Among Women Engaged in Sex Work: A Randomized Clinical Trial

Background and Purpose:  Poverty, gender inequity and partner violence are major structural risks that limit the effectiveness of HIV prevention for women. For women engaged in sex work, the need to rely on sexual behavior for economic support compromises the ability to be concerned with the long term health consequences associated with risk-taking. Interventions that address structural risk environments of HIV are needed for women engaged in sex work. We tested whether a structural intervention combining savings-led microfinance and HIV prevention components would achieve enhanced sexual risk reduction among women engaging in street-based sex work in Ulaanbaatar, Mongolia, compared to an HIV prevention intervention alone.   

Methods:  Targeted sampling was used to identify 10 street-based sex work locations at which women were approached for screening.  Eligible women (n=107) completed baseline assessments and were randomized to either a 4 session HIV sexual risk reduction intervention (HIVSRR) alone (n=50) or to a 34 session HIVSRR plus savings-led microfinance condition (n=57). Follow-up assessments at 3 and 6 months examined unprotected acts of vaginal intercourse with paying partners and the number of paying partners reported by each participant in the prior 90 days. Poisson and zero-inflated Poisson model regressions were used to examine the effects of assignment to the treatment versus the control condition on outcomes.

Results: Women in both groups exhibited a 31% decrease in the number of paying sexual partners at each time point. Women in the microfinance group exhibited a 22% greater decrease in the reported number of paying sexual partners, compared to those in the control group, for each time point (IRR=.78, 95% CI [0.67,0.71], p<.0001). Women in both groups exhibited a 39% decrease in the number of unprotected vaginal sex acts at each time point, and there was no main effect of the microfinance group, or group by time interaction (IRR=0.61, 95% CI [0.57,0.66]; p<.0001).  Women assigned to the microfinance group, however, were more likely to report no unprotected vaginal sex acts at the 6-months (OR=3.72, 95% CI [-0.37, 7.80]; p=.05).  Women assigned to the microfinance group reported 50% fewer paying sexual partners at the 6-month time point (IRR=0.50, 95% CI [0.31,0.78]; p=.01).

Conclusions and Implications: This study was the first successful test of a savings-led microfinance intervention in support of HIV prevention among women engaged in sex work.  Findings advance the gender-specific HIV and STI prevention repertoire for women by addressing structural level factors influencing their enhanced risk for HIV and other STIs.  Unique to the study was the choice of an asset-based approach due to the high levels of stigma and discrimination the women face, associated with both their sex work and harmful alcohol use, which excludes them from opportunities for microloans or increases their vulnerability to be economically exploited.  Further research is needed to identify the best ways to replicate, disseminate and sustain such interventions through the support of collaborations with government, NGO and global partners.