Project Nova: A Combination Microfinance and HIV Prevention Intervention for Vulnerable Women in Kazakhstan

Background:  UNAIDS estimates that one in nine cases of HIV infection in Central Asia occurs among women engaged in sex work or their paying partners.  Most women engaged in sex work who use drugs in Kazakhstan are street-based, facing extreme poverty, stigma and gender-based violence. Given the critical role that these structural drivers play in shaping womens’ risk for HIV infection, prevention interventions must address risk factors beyond the individual level, e.g. the addition of microfinance components that increase economic empowerment and alternative options for income that do not put women at risk.

Methods: This paper describes the development and implementation of Nova, the first cluster randomized controlled trial of a structural HIV prevention intervention integrating microfinance components to target women who trade sex and use drugs in Central Asia. Intervention sessions combining financial literacy training, vocational training and matched savings components into HIV risk reduction were adapted and piloted for cultural context with input from women in the target community and key stakeholders, and piloted prior to the trial. From 2014-2017 Nova enrolled 354 women engaged in sex work and drug use in Kazakhstan. Session facilitators received weekly supervision. Using quantitative and qualitative data, we provide session attendance rates, describe barriers to engagement, challenges to session facilitation, as well as solutions developed to achieve successful intervention implementation.

Results: The adapted HIV risk reduction and microfinance components were successfully implemented with 354 women with relatively good attendance, which was unexpected, given the many life challenges these women face.  Women’s ability to attend even the lengthy and intensive vocational training intervention supports the fact that women with multiple stigmatized identities are able to actively engage in a multicomponent, multisession intervention.  Over 80% of randomized women attended at least three of four risk reduction sessions; four of six financial literacy sessions and 18 of 24 vocational training sessions. Barriers to attendance included drug use, transportation expenses, intermittent police detention, and conflicting work schedules. Principal facilitation challenges during delivery of the risk reduction sessions were related to explicit discussions about sex and protective behaviors, condom use with all partners and use of communication techniques.  Challenges arising in microfinance sessions included balancing savings goals with daily survival needs; suspicion of formal banking; budgeting; and transitioning vocational training to alternative employment. Facilitators demonstrated flexibility, responding to challenges with creative and effective solutions.

Conclusion: Findings contribute to the global effort to achieve the UNAIDS goals of 90-90-90 by 2030 focusing special attention to the needs of one of the groups most vulnerable to HIV infection, women engaged in sex work and who use drugs. Findings demonstrate feasibility to implement a structural, combination prevention intervention with highly vulnerable women and successful problem solving on the part of facilitators to address implementation challenges. Further, session facilitation lessons may be integrated into protocols for wider scale dissemination to similar populations at risk globally.