Women engaged in sex work (WESW) and who use drugs are at high risk for both HIV infection and intimate and paying partner violence, with prevalence estimates of past year violence ranging from 32-55%. Increasingly studies have tested the impact of interventions for women at the intersections of HIV and IPV, but these have not targeted WESW. Another frontier for intervention targeting WESW is combination HIV risk reduction (HIVRR) and microfinance (MF) interventions aimed at reducing reliance on sex work for income, theoretically reducing HIV transmission exposure. Mixed results show that such interventions may sometimes increase violence for women as they become economically empowered. Closer examination of the impact on violence prevention of combination interventions is needed. The aim of this study was to examine the impact of a combination HIVRR and microfinance intervention on reducing paying and intimate partner violence against WESW who use drugs in Kazakhstan.
This study used a cluster randomized controlled trial to evaluate whether participants assigned to a combination HIVRR and MF intervention report reduced rates of IPV and paying partner violence compared to those assigned to an HIVRR intervention alone. Eligible participants were over 18 years, reported illicit drug use within the past year, having sex in return for money, goods, drugs or services within the past 90 days; and at least one incidence of unprotected sex within the past 90 days. Between 2015 and 2018, the study enrolled and randomized 354 women to two conditions, assessing outcomes at 4 time points over 15 months, encompassing up to 3 months of intervention activities and 12 months of follow-up. We tested the change in rates of recent violence perpetrated by a 1) current intimate partner; 2) past intimate partner; and/or 3) commercial partner by study arm, over time. Violence was defined as physical, psychological, sexual and/or severe. These variables were calculated as the raw sum of each IPV type experienced in the prior 90 days. Data analysis used zero-inflated Poisson mixture regression within a Bayesian approach to account for missing data, adjusted for clustering to account for repeated measures, included random intercepts, and adjusted for sociodemographic covariates.
Findings show significant intervention effects over 12 months. Participants in the intervention group had significantly lower rates of physical (-19%), psychological (-13%), sexual (-26%) and severe (-15%) IPV from past intimate partners. Similarly, participants in the intervention group reported significantly lower rates of sexual (-19%) and severe (-10%) violence from paying partners compared to the control group. The rates of physical violence were lower compared with the control group (-10%), though only approaching statistical significance (p=0.07). We did not find significant differences in IPV rates from current intimate partners.
Findings indicate that a combination HIVRR and microfinance intervention may reduce paying and past partner violence among women engaged in sex work who use drugs above and beyond HIVRR interventions alone. Future research should replicate these findings in other regions, while also examining which components or mechanisms of microfinance may be associated with such reductions.