The evaluation of the JEWEL project: an innovative economic enhancement and HIV prevention intervention study targeting drug using women involved in prostitution

Empowerment at Work?: Examining Employment-Based Economic Empowerment Initiatives for Survivors of Commercial Sexual Exploitation

Many organizations serving survivors of commercial sexual exploitation (CSE) have begun economic empowerment programs, providing financial literacy education, vocational training, and/or employment opportunities for survivors. Yet, very little research has examined these programs, especially those that employ survivors. This project draws on a qualitative, multi-method study of 15 organizations that serve and employ CSE survivors to examine how economic empowerment is constructed through organizational discourse and practices, what tensions emerge in these processes, and how organizational actors frame and respond to them. The findings outline the components of "economic empowerment" and explicate the key tensions of authority-autonomy and compassion-accountability.

Exploring the Impact of an Integrated Trauma-Informed HIV and Vocational Intervention for Black/African American Women Living with HIV

Given the increased recognition of the role of social determinants of health on the prevalence of HIV in the United States, interventions that incorporate and address social determinants of HIV are essential. In response to the health disparities facing Black/African American women living with HIV, HIV activists and mental health specialists developed an innovative integrated HIV prevention and vocational development intervention, Common Threads, that underscores and addresses key economic and other social determinants of health experienced by Black/African American women within a trauma-informed care (TIC) framework. This research study applied grounded theory methods to conduct a qualitative study of Common Threads based on interviews with 21 women who participated in the Common Threads intervention. Participants shared several critical aspects of program components that reflected the TIC principles, endorsing a safe environment, trust building, and a sense of belonging. These components also encouraged transparency and promoted autonomy. Additionally, participants shared perceived program outcomes, including changes of knowledge and skills in four considering work domains (i.e., medical, psychosocial financial/legal resources, and vocational) that facilitate health and vocational development.

Interventions to improve health and the determinants of health among sex workers in high-income countries: a systematic review

Many sex worker populations face high morbidity and mortality, but data are scarce on interventions to improve their health. We did a systematic review of health and social interventions to improve the health and wider determinants of health among adult sex workers in high-income countries. We searched MEDLINE, Embase, PsycINFO, CINAHL, the Cochrane Library, Web of Science, EthOS, OpenGrey, and Social Care Online, as well as the Global Network of Sex Work Projects and the Sex Work Research Hub for studies published between Jan 1, 2005 and Dec 16, 2021 (PROSPERO CRD42019158674). Quantitative studies reporting disaggregated data for sex workers were included and no comparators were specified. We assessed rigour using the Quality Assessment Tool for Quantitative Studies. We summarised studies using vote counting and a narrative synthesis. 20 studies were included. Most reported findings exclusively for female sex workers (n=17) and street-based sex workers (n=11). Intervention components were divided into education and empowerment (n=14), drug treatment (n=4), sexual and reproductive health care (n=7), other health care (n=5), and welfare (n=5). Interventions affected a range of mental health, physical health, and health behaviour outcomes. Multicomponent interventions and interventions that were focused on education and empowerment were of benefit. Interventions that used peer design and peer delivery were effective. An outreach or drop-in component might be beneficial in some contexts. Sex workers who were new to working in an area faced greater challenges accessing services. Data were scarce for male, transgender, and indoor-based sex workers. Co-designed and co-delivered interventions that are either multicomponent or focus on education and empowerment are likely to be effective. Policy makers and health-care providers should improve access to services for all genders of sex workers and those new to an area. Future research should develop interventions for a greater diversity of sex worker populations and for wider health and social needs.

Economic vulnerability, violence, and sexual risk factors for HIV among female sex workers in Tijuana, Mexico

Economic vulnerability is often reported to underlie involvement in sex work among female sex workers (FSW), but may also create urgency in women's work, limiting women's negotiating power with clients and in turn, increasing their vulnerability for violence and HIV. This study assessed economic vulnerability in relation to violence and sexual risk behaviors for HIV among a sample of FSW in Tijuana, Mexico. FSW at least 18 years of age were recruited through venue-based sampling for a survey (n = 228) and in-depth interviews (n = 50) to investigate HIV risk factors in this region. Using crude and adjusted logistic regression models, we assessed lack of financial support from others as well as reports of financial hardship separately in relation to experiencing sexual violence (e.g. by clients, police, relationship partners, in the past 6 months), physical violence (past 6 months), STI diagnosis, and inconsistent condom use (past 30 days). Qualitative interviews (n = 50), conducted with a subsample of the survey participants, were also examined for related themes. FSW who reported no financial support were more likely to report sexual violence (OR = 2.1; 95% CI:1.1-4.2). FSW who reported financial hardship were more likely to experience sexual violence (OR = 1.9; 95% CI:1.1-3.6) and physical violence (OR = 1.9; 95% CI:1.1-3.6), as well as to report past 30-day inconsistent condom use (OR = 2.4; 95%CI: 1.3-4.6) and to test positive for an STI (OR = 1.9; 95% CI:1.1-3.4). Qualitative data substantiated these findings. Findings suggest that interventions to improve economic well-being may be useful to prevent the intersecting concerns of violence and HIV among FSW.

Cultivating PEARL (Promoting Empowerment and Risk Reduction): Formative Research for a PrEP Intervention Among Female Sex Workers in Baltimore, Maryland

Pre-exposure prophylaxis (PrEP) is a vital component of comprehensive HIV prevention among female sex workers (FSW). There are limited PrEP interventions targeting FSW in the U.S., who have high HIV risk. Formative research was conducted to inform PEARL (Promoting Empowerment And Risk Reduction), a PrEP intervention for FSW in Baltimore, MD, including a community forum, key informant interviews with providers, and focus group discussions with FSW. FSW and providers acknowledged challenges to building rapport and establishing continuity in care settings. FSW reported low PrEP awareness, with high interest once aware. FSW and providers reported uptake barriers including perceived financial issues, lack of PrEP awareness, and mistrust of the pharmaceutical industry. Concerns were raised about substance use and daily PrEP adherence. Developing a tailored PrEP intervention for FSW necessitates multiple perspectives (e.g. FSW, service providers). Resumen La profilaxis preexposición (PrEP) es un componente vital de la prevención integral del VIH para las trabajadoras sexuales (TSF). En los Estados Unidos, hay pocas intervenciones de PrEP dirigidas a las TSF, quienes experiencian un riesgo elevado de contraer el VIH. Se realizó una investigación formativa para informar a PEARL (Promoción del empoderamiento y la reducción de riesgos), una intervención de PrEP para TSF en Baltimore, MD-la cual incluyó un foro comunitario, entrevistas con proveedores de servicios a las TSF y discusiones entre grupos focales de TSF. TSF y proveedores de servicio reconocieron los retos de mantener buenas relaciones y establecer continuidad en los servicios de salud. TSF exhibieron conocimiento limitado sobre la PrEP, pero expresaron gran interés en la PrEP después de estar informadas. TSF y los proveedores de servicios hablaron de barreras aceptando a la PrEP, incluyendo problemas financieros percibidos, falta de conocimiento sobre la PrEP y desconfianza en la industria farmacéutica. Se expresaron preocupaciones sobre el uso de sustancias y la adherencia diaria a la PrEP. El desarrollo de una intervención de PrEP personalizada para TSF requiere varias perspectivas (por ejemplo, TSF, proveedores de servicios).

'I never hoped for anything … now I have other plans': The role of microfinance in HIV intervention for women who use drugs and engage in sex work in Kazakhstan

Over the past decade, Kazakhstan has experienced increased cases of HIV, especially among women who engage in sex work and use drugs. Research has examined the efficacy of structural interventions to reduce HIV risk; however, few studies have examined the experiences of women participating in these interventions. This study aimed to understand the perceived impact that HIV risk reduction and savings-led microfinance components of the Nova study had on women's sexual and drug risk behaviors as well as their capacity for reducing income from sex work and finding alternative sources of income over time. The Nova study is a cluster-randomized controlled trial conducted from 2013 to 2018 in Kazakhstan. It examines the efficacy of a combination of HIV risk reduction and microfinance among women who engage in sex work and women who use drugs. Data were drawn from the qualitative component of this study; 56 interviews with 19 participants were conducted. Template analysis and a qualitative trajectory approach were used to understand women's perceptions of the impact that intervention had over time. Findings indicated that women perceived increased knowledge and skills related to condom use, safe sex practice, and drug use reduction. Women who received the microfinance component described perceived gains on budget management, capacity to plan for their future, and motivation to find alternative sources of income. Giving women the opportunity to express narrative experiences over time regarding the impact of this structural intervention may inform needed cultural adaptations of the intervention components and nuances of the environment in which the intervention is offered.

Crystal methamphetamine use subgroups and associated addiction care access and overdose risk in a Canadian urban setting

OBJECTIVES

Methamphetamine use is rising globally and we have limited treatments for this. Subgroups within the diverse methamphetamine-using population may have distinct treatment needs. Among a community-recruited sample of people who use crystal methamphetamine, we aimed to identify subgroups and characterize their overdose risk and access to addiction care.

METHODS

Data from prospective cohorts of people who use drugs in Vancouver, Canada from 2014 to 2018 were used to conduct a repeated measures latent class analysis among participants who used crystal methamphetamine. Multivariable generalized estimating equations models were fit to determine the associated factors.

RESULTS

Among 824 eligible participants, a five-class model was identified as the best fit: (1) primary stimulant use (15.7%); (2) women engaged in sex work and opioid use (21.4%); (3) street income generation and opioid use (31.6%); (4) opioid agonist therapy (OAT) patients (22.3%); and (5) men who have sex with men (9.0%). In multivariable analyses, compared to the primary stimulant use group, non-fatal overdose was positively associated with street income generation (adjusted odds ratio [AOR] = 1.49, 95% confidence interval [95% CI]=1.30-1.71), sex work (AOR = 1.38, 95% CI=1.20-1.59) and OAT (AOR = 1.22, 95% CI=1.06-1.41) subgroups; engagement in non-OAT addiction care was negatively associated with street income generation (AOR = 0.81, 95% CI=0.68-0.97) and sex work (AOR = 0.78, 95% CI=0.63-0.98) subgroups.

DISCUSSION

Socioeconomically marginalized subgroups with opioid and crystal methamphetamine co-use were at highest risk of non-fatal overdose and had poorer access to addiction care, highlighting the need for tailored interventions.

Client Characteristics Associated with Desire for Additional Services at Syringe Exchange Programs

Objectives

The objective of this study was to explore the relationship between client characteristics and desired services offered at syringe exchange program (SEP) sites among women who inject drugs (WWID). We investigated whether a desire for additional services varied as a function of these client characteristics.

Methods

A sample of 69 women who were syringe exchange clients participated in a survey about adding services to syringe exchange programs. Three Poisson regression analyses were run to examine if client age, education, housing status, polysubstance use, and previous pregnancies were associated with overall desire for services, desire for health-related services, and desire basic needs services.

Results

Participant characteristics of polysubstance use (IRR 1.62, 95% CI 1.34-1.96; p < .01) and greater number of previous pregnancies (IRR 1.14, 95% CI 1.08-1.22; p < .05), were predictive of a greater number of desired services. Engagement in polysubstance use was predictive of a greater number of desired basic need services (IRR 1.45, 95% CI 1.23-1.70; p < .05).

Conclusions

WWID desired services at SEP sites can inform policymakers to formulate policies to better promote utilization of health-related and basic need services among WWID and, in turn, facilitate improved outcomes for WWID.

Perceived Facilitators and Barriers to Participating in a Combination Income-Generating HIV Risk-Reduction Intervention Among Adolescent Girls and Young Women in Nigeria: A Qualitative Study

Background: Human immunodeficiency virus risk-reduction interventions that include income-generating activities are garnering attention as effective strategies to engage adolescent girls and young women (AGYW) toward HIV risk reduction. To sustain and promote the uptake of these interventions, researchers must understand factors that may encourage or present barriers to AGYW participation in such interventions. This study explores AGYW perceived barriers and facilitators to participation in a school-based combination income-generating HIV prevention intervention in Nigeria.

Methods: A convenience sample of AGYW who participated in a school-based combination income-generating HIV prevention intervention were recruited for the study. Data generated from focus group discussions (FGDs) (eight discussion groups comprising 10–12 participants) were analyzed by inductive thematic analysis.

Results: A total of 93 participants with a mean age of 15.04 years (SD = 0.89) participated in the FGDs. The study participants identified several facilitators and barriers to participation in the intervention. Three main themes that emerged as facilitators were: (1) involvement of young female facilitators in the delivery of intervention components, (2) opportunity for social interaction with peers during the intervention period, and (3) support and approval from school authorities. Two main themes were also identified as barriers: (1) sexual conservatism from society and parents and (2) challenges in sustaining a microenterprise.

Conclusions: Despite the perceived benefits and interest in participation in the intervention, the study participants outlined some challenges that may hinder participation in the intervention components. Addressing barriers, such as stigma associated with the discussion of sexual health-related topics, coupled with the promotion of facilitating factors, such as leveraging context-appropriate intervention delivery modalities, is important for enhancing the engagement of AGYW in HIV risk-reduction intervention. Our findings can guide future research and design of combination income-generating HIV prevention interventions for in-school AGYW in low-resource settings such as Nigeria.

Examining differences between mass, multiple, and single-victim homicides to inform prevention: findings from the National Violent Death Reporting System

Background

Multi-victim homicides are a persistent public health problem confronting the United States. Previous research shows that homicide rates in the U.S. are approximately seven times higher than those of other high-income countries, driven by firearm homicide rates that are 25 times higher; 31% of public mass shootings in the world also occur in the U.S.. The purpose of this analysis is to examine the characteristics of mass, multiple, and single homicides to help identify prevention points that may lead to a reduction in different types of homicides.

Methods

We used all available years (2003–2017) and U.S. states/jurisdictions (35 states, the District of Columbia, and Puerto Rico) included in CDC’s National Violent Death Reporting System (NVDRS), a public health surveillance system which combines death certificate, coroner/medical examiner, and law enforcement reports into victim- and incident-level data on violent deaths. NVDRS includes up to 600 standard variables per incident; further information on types of mental illness among suspected perpetrators and incident resolution was qualitatively coded from case narratives. Data regarding number of persons nonfatally shot within incidents were cross-validated when possible with several other resources, including government reports and the Gun Violence Archive. Mass homicides (4+ victims), multiple homicides (2-3 victims) and single homicides were analyzed to assess group differences using Chi-square tests with Bonferroni-corrected post-hoc comparisons.

Results

Mass homicides more often had female, child, and non-Hispanic white victims than other homicide types. Compared with victims of other homicide types, victims of mass homicides were more often killed by strangers or someone else they did not know well, or by family members. More than a third were related to intimate partner violence. Approximately one-third of mass homicide perpetrators had suicidal thoughts/behaviors noted in the time leading up to the incident. Multi-victim homicides were more often perpetrated with semi-automatic firearms than single homicides. When accounting for nonfatally shot victims, over 4 times as many incidents could have resulted in mass homicide.

Conclusions

These findings underscore the important interconnections among multiple forms of violence. Primary prevention strategies addressing shared risk and protective factors are key to reducing these incidents.

What Racism Has to Do with It: Understanding and Reducing Sexually Transmitted Diseases in Youth of Color

Sexually transmitted diseases (STDs) are high in populations of color compared to Whites. High-risk sexual behaviors are widely viewed as the key contributors to the levels of STDs, especially in adolescents and young adults. This article situates the sexual risk behaviors of Black, Indigenous, and other young people of color within the framework of racism. It begins with an overview of racial inequities in common STDs and shows how racism gives rise to several risk factors for high-risk sexual behaviors. These risk factors for STDs identified in prior research are best understood as adaptations to the challenges and constraints faced by youth in socially disadvantaged environments. Both social adversity and the mental health problems that it triggers can lead to risky sexual behaviors. Drawing on findings from prior research with youth of color, this paper describes the needed interventions that can markedly reduce STDs and their risk factors. It also describes needed research on interventions that could contribute to the knowledge and understanding of the adverse conditions fueled by racism that affect youth of color, their health, and their communities.

A cluster-randomized controlled trial of a combination HIV risk reduction and microfinance intervention for female sex workers who use drugs in Kazakhstan

INTRODUCTION

Female sex workers (FSW) who use drugs are a key population at risk of HIV in Kazakhstan, and face multiple structural barriers to HIV prevention. More research is needed on the role of structural interventions such as microfinance (MF) in reducing HIV risk. This paper describes the results of a cluster-randomized controlled trial to test the efficacy of a combination HIVRR + MF intervention in reducing biologically confirmed STIs and HIV risk behaviours.

METHODS

This study took place from May 2015 to October 2018 in two cities in Kazakhstan. We screened 763 participants for eligibility and enrolled 354 FSW who use drugs. Participants were randomized in cohorts to receive either a four-session HIVRR intervention, or that same intervention plus 30 additional sessions of financial literacy training, vocational training and asset-building through a matched-savings programme. Repeated behavioural and biological assessments were conducted at baseline, 3-, 6- and 12-months post-intervention. Biological and behavioural primary outcomes included HIV/STI incidence, sexual risk behaviours and drug use risk behaviours, evaluated over the 12-month period.

RESULTS

Over the 12-month follow-up period, few differences in study outcomes were noted between arms. There was only one newly-detected HIV case, and study arms did not significantly differ on any STI incidence. At post-intervention assessments compared to baseline, both HIVRR and HIVRR + MF participants significantly reduced sexual and drug use risk behaviours, and showed improvements in financial outcomes, condom use attitudes and self-efficacy, social support, and access to medical care. In addition, HIVRR + MF participants showed a 72% greater reduction in the number of unprotected sex acts with paying partners at the six-month assessment (IRR = IRR = 0.28, 95% CI = 0.08, 0.92), and a 10% greater reduction in the proportion of income from sex work at the three-month assessment (b = -0.10, 95% CI = -0.17, -0.02) than HIVRR participants did. HIVRR + MF participants also showed significantly improved performance on financial self-efficacy compared to HIVRR over the 12-month follow-up period.

CONCLUSIONS

Compared to a combination HIVRR + MF intervention, a robust HIVRR intervention alone may be sufficient to reduce sexual and drug risk behaviours among FSW who use drugs. There may be structural limitations to the promise of microfinance for HIV risk reduction among this population.

90 DAYS: An investigation of a short entertainment-education film to improve HIV status disclosure among black women living with HIV in Miami-Dade County

Within Miami-Dade County, Black women experience disproportionate rates of HIV incidence and prevalence. Status disclosure to sexual partners is central to mitigating the HIV epidemic and ensuring a healthier lifestyle for those living with the virus. The disclosure processes model (DPM) posits that barriers such as stigma and negative outcome expectations often facilitate disclosure avoidance. Therefore, this study investigated the utility and acceptability of an entertainment-education (EE) short film, 90 DAYS, for disclosure among Black women living with HIV in Miami-Dade County. Employing photo-elicitation (Harper, 2002), focus groups were conducted with 48 participants. After screening the 90 DAYS film about stigma and disclosure, participants were asked semi-structured questions based upon extant EE and DPM literature. Via inductive and deductive processes, five themes were derived from the data. Participants found the 90 DAYS film to be an empowering counter-narrative that could be used to overcome multiple disclosure-related factors. They felt it provided a social script for how to disclose to their sexual partners. A novel finding of this investigation was that respondents asserted the film could facilitate safer disclosure events. Additional themes included the film being a resource of hope for young and newly diagnosed women; and an educational tool for the community. Altogether, findings lend promise to the use of EE for addressing disclosure avoidance among Black women living with HIV.

Long term pre-treatment opioid use trajectories in relation to opioid agonist therapy outcomes among people who use drugs in a Canadian setting

BACKGROUND

Opioid agonist therapy (OAT) models are generally provided without consideration of how pre-treatment characteristics may be associated with outcome. Therefore, we aimed to first characterize longitudinal trajectories of opioid use before initiating OAT. Then we explored the impact of OAT on opioid use across these pre-treatment trajectories.

METHODS

Data were derived from three prospective cohort studies involving people who use drugs in Vancouver, Canada. Latent class growth analysis was applied to identify opioid use trajectories based on individual-level observations three years before starting OAT. Multivariable generalized linear mixed model was used to examine whether engaging in OAT was associated with lower risk of illicit opioid use among participants with different pre-treatment opioid use trajectories.

RESULTS

464 participants were included in the study between September 2005 and November 2018. Two pre-treatment opioid use trajectories were identified: high frequency users (246, 53.0%) and gradually increasing frequency users (218, 47.0%). We observed different strengths of association between OAT engagement and illicit opioid use among high frequency users (adjusted odds ratio [AOR] = 0.36, 95% Confidence Interval [CI]: 0.20 - 0.63) and gradually increasing frequency users (AOR = 0.91, 95% CI: 0.53 - 1.56). Unstable housing, any stimulant use, experiencing violence, drug dealing, sex work involvement, and incarceration were independently and positively associated with ongoing illicit opioid use.

CONCLUSIONS

Distinct pre-treatment opioid use trajectories are likely to influence treatment outcomes. Research is required to determine if tailored strategies specific to people with different pre-treatment opioid use patterns have potential to improve outcomes of OAT.

Drug Use in Street Sex worKers (DUSSK) study: results of a mixed methods feasibility study of a complex intervention to reduce illicit drug use in drug dependent female sex workers

OBJECTIVES

The majority of female street-based sex workers (SSWs) are dependent on illicit drugs and sell sex to fund their drug use. They typically face multiple traumatic experiences, starting at a young age, which continue through sex work involvement. Their trauma-related symptoms tend to increase when drug use is reduced, hindering sustained reduction. Providing specialist trauma care to address post-traumatic stress disorder (PTSD) alongside drug treatment may therefore improve treatment outcomes. Aims to (1) evaluate recruitment and retention of participants; (2) examine intervention experiences and acceptability; and (3) explore intervention costs using a mixed methods feasibility study.

SETTING

Female SSW charity premises in a large UK inner city.

PARTICIPANTS

Females aged 18 years or older, who have sold sex on the street and used heroin and/or crack cocaine at least once a week in the last calendar month.

INTERVENTION

Female SSW-only drug treatment groups in a female SSW-only setting delivered by female staff. Targeted PTSD screening then treatment of positive diagnoses with eye movement desensitisation and reprocessing (EMDR) therapy by female staff from a specialist National Health Service trauma service.

RESULTS

(1) Of 125 contacts, 11 met inclusion criteria and provided informed consent, 4 reached the intervention final stage, (2) service providers said working in collaboration with other services was valuable, the intervention was worthwhile and had a positive influence on participants. Participants viewed recruitment as acceptable and experienced the intervention positively. The unsettled nature of participant's lives was a key attendance barrier. (3) The total cost of the intervention was £11 710, with staff costs dominating.

CONCLUSIONS

Recruitment and retention rates reflected study inclusion criteria targeting women with the most complex needs. Two participants received EMDR demonstrating that the three agencies working together was feasible. Staff heavy costs highlight the importance of supporting participant attendance to minimise per participant costs in a future trial.

Microenterprise Intervention to Reduce Sexual Risk Behaviors and Increase Employment and HIV Preventive Practices Among Economically-Vulnerable African-American Young Adults (EMERGE): A Feasibility Randomized Clinical Trial

Economic vulnerability, such as homelessness and unemployment, contributes to HIV risk among U.S. racial minorities. Yet, few economic-strengthening interventions have been adapted for HIV prevention in this population. This study assessed the feasibility of conducting a randomized clinical trial of a 20-week microenterprise intervention for economically-vulnerable African-American young adults. Engaging MicroenterprisE for Resource Generation and Health Empowerment (EMERGE) aimed to reduce sexual risk behaviors and increase employment and uptake of HIV preventive behaviors. The experimental group received text messages on job openings plus educational sessions, mentoring, a start-up grant, and business and HIV prevention text messages. The comparison group received text messages on job openings only. Primary feasibility objectives assessed recruitment, randomization, participation, and retention. Secondary objectives examined employment, sexual risk behaviors, and HIV preventive behaviors. Outcome assessments used an in-person pre- and post-intervention interview and a weekly text message survey. Several progression criteria for a definitive trial were met. Thirty-eight participants were randomized to experimental (n = 19) or comparison group (n = 19) of which 95% were retained. The comparison intervention enhanced willingness to be randomized and reduced non-participation. Mean age of participants was 21.0 years; 35% were male; 81% were unemployed. Fifty-eight percent (58%) of experimental participants completed ≥ 70% of intervention activities, and 74% completed ≥ 50% of intervention activities. Participation in intervention activities and outcome assessments was highest in the first half (~ 10 weeks) of the study. Seventy-one percent (71%) of weekly text message surveys received a response through week 14, but responsiveness declined to 37% of participants responding to ≥ 70% of weekly text message surveys at the end of the study. The experimental group reported higher employment (from 32% at baseline to 83% at week 26) and lower unprotected sex (79% to 58%) over time compared to reported changes in employment (37% to 47%) and unprotected sex (63% to 53%) over time in the comparison group. Conducting this feasibility trial was a critical step in the process of designing and testing a behavioral intervention. Development of a fully-powered effectiveness trial should take into account lessons learned regarding intervention duration, screening, and measurement.Trial Registration ClinicalTrials.gov. NCT03766165. Registered 04 December 2018. https://clinicaltrials.gov/ct2/show/NCT03766165.

Patterns, contexts, and motivations for polysubstance use among people who inject drugs in non-urban settings in the U.S. Northeast

BACKGROUND

Polysubstance use (i.e., using ≥2 psychoactive substances concomitantly) is associated with increased morbidity and mortality and complicates drug treatment needs among people who inject drugs (PWID). We explored patterns, contexts, motivations, and perceived consequences of polysubstance use among PWID in small cities and towns in the U.S. Northeast.

METHODS

Between October 2018 and March 2019, we conducted semi-structured interviews with 45 PWID living outside of the capital cities of Rhode Island and Massachusetts recruited online and through community-based organizations. Written transcripts were coded inductively and deductively using a team-based approach and analyzed thematically.

RESULTS

All participants reported recent polysubstance use, with most using five or more classes of substances in the past three months. Polysubstance use often followed long personal drug use histories (i.e., years or decades of occasional drug use). Reasons for polysubstance use included obtaining synergistic psychoactive effects as a result of mixing drugs (i.e., using drugs to potentiate effects of other drugs) and managing undesirable effects of particular drugs (e.g., offsetting the depressant effects of opioids with stimulants or vice-versa). Polysubstance use to self-medicate poorly managed physical and mental health conditions (e.g., chronic pain, anxiety, and depression) was also reported. Inadequately managed cravings and withdrawal symptoms prompted concomitant use of heroin and medications for opioid use disorder, including among individuals reporting cocaine or crack as their primary "issue" drugs. Polysubstance use was perceived to increase overdose risks and to be a barrier to accessing healthcare and drug treatment services.

CONCLUSION

Healthcare services and clinicians should acknowledge, assess, and account for polysubstance use among patients and promote harm reduction approaches for individuals who may be using multiple drugs. Comprehensive healthcare that meets the social, physical, mental health, and drug treatment needs of PWID may decrease the perceived need for polysubstance use to self-medicate poorly managed health conditions and symptoms.

Associations Between Economic Factors and Condom Use Behavior Among Female Sex Workers in Dakar and Mbour, Senegal

Condom use remains a mainstay of HIV prevention programs around the world. However, data characterizing economic determinants of condom use among female sex workers (FSW) are limited, including in Senegal. We recruited 718 FSWs via respondent-driven sampling. Bivariate and multivariable regressions were conducted to assess the associations between economic variables and condom use at last sex. Paying rent (aRR: 1.07, 95%CI 1.01-1.13) was positively associated with condom use at last sex with new clients. No statistically significant associations were found between condom use and financial responsibility for dependent children, having additional source of income, sharing sex work earnings, or the ability to borrow from other FSWs, regardless of sexual partner types. The relationship between economic marginalization and consistent condom use among sex workers is complex reinforcing the need for behavioral economic research and prevention to be integrated into HIV prevention and treatment research and programs.

Feasibility of Assessing Economic and Sexual Risk Behaviors Using Text Message Surveys in African-American Young Adults Experiencing Homelessness and Unemployment: Single-Group Study

Background

Text messages offer the potential to better evaluate HIV behavioral interventions using repeated longitudinal measures at a lower cost and research burden. However, they have been underused in US minority settings.

Objective

This study aims to examine the feasibility of assessing economic and sexual risk behaviors using text message surveys.

Methods

We conducted a single-group study with 17 African-American young adults, aged 18-24 years, who were economically disadvantaged and reported prior unprotected sex. Participants received a text message survey once each week for 5 weeks. The survey contained 14 questions with yes-no and numeric responses on sexual risk behaviors (ie, condomless sex, sex while high or drunk, and sex exchange) and economic behaviors (ie, income, employment, and money spent on HIV services or products). Feasibility measures were the number of participants who responded to the survey in a given week, the number of questions to which a participant responded in each survey, and the number of hours spent from sending a survey to participants to receiving their response in a given week. One discussion group was used to obtain feedback.

Results

Overall, 65% (n=11/17) of the participants responded to at least one text message survey compared with 35% (n=6/17) of the participants who did not respond. The majority (n=7/11, 64%) of the responders were women. The majority (n=4/6, 67%) of nonresponders were men. An average of 7.6 participants (69%) responded in a given week. Response rates among ever responders ranged from 64% to 82% across the study period. The mean number of questions answered each week was 12.6 (SD 2.7; 90% of all questions), ranging from 72% to 100%. An average of 6.4 participants (84%) answered all 14 text message questions in a given week, ranging from 57% to 100%. Participants responded approximately 8.7 hours (SD 10.3) after receiving the survey. Participants were more likely to answer questions related to employment, condomless sex, and discussions with sex partners. Nonresponse or skip was more often used for questions at the end of the survey relating to sex exchange and money spent on HIV prevention services or products. Strengths of the text message survey were convenience, readability, short completion time, having repeated measures over time, and having incentives.

Conclusions

Longitudinal text message surveys may be a valuable tool for assessing HIV-related economic and sexual risk behaviors.

Trial Registration

ClinicalTrials.gov NCT03237871; https://clinicaltrials.gov/ct2/show/NCT03237871

Drug use, sexual risk, and structural vulnerability among female sex workers in two urban centers of the Dominican Republic: The EPIC study

BACKGROUND

Evidence in different countries suggest an association between sex work and drug use. In the Dominican Republic an estimated 60,000-100,000 women work in the sex industry. However, little is known about their drug use behaviors.

OBJECTIVE

To characterize the burden of drug use and examine correlates of these behaviors among female sex workers in the Dominican Republic.

METHODS

Data for this analysis comes from a cross-sectional study among key populations at risk for HIV. A community sample of female sex workers (N = 389) was recruited using passive and active recruitment strategies. Participants completed a behavioral survey between 2015 and 2016. Logistic regression models were constructed to examine predictors of drug use.

RESULTS

Protective factors against marijuana and crack or cocaine use included being heterosexual, having a higher level of education, regular employment, and fewer male sexual partners. Increased odds of crack or cocaine use were associated with incarceration, having slept in a place not meant for human habitation in the last six months, and having ever lived in a batey (a community around a sugar mill where workers and their families live). Participants that used marijuana were generally younger, while those that used crack or cocaine were older.

CONCLUSIONS

Our findings highlight characteristics of the social and economic environment that require further research to optimize prevention and care strategies for this population. Public health interventions are needed that address drug use, sexual risk-taking, and helping female sex workers and their families achieve a healthy life.

Social and structural determinants of health associated with drug use patterns among female sex workers in Iran: A latent class analysis

BACKGROUND

Female sex workers (FSWs) experience adversities regarding social determinants of health (SDH) and behavioural factors including illicit drug use. This study aimed to assess the clustered impact of SDH on illicit drug use among FSWs in Iran.

METHODS

We surveyed 1,347 FSWs in 13 major cities in 2015. Latent class analysis was conducted to identify distinct classes of five measured SDH including low education, unemployment, unstable housing, last-year incarceration and sexual violence. We examined the association of these classes with five illicit drug use patterns using multivariable generalized linear model with Poisson family and log link, and reported adjusted prevalence ratios (aPR) and their 95% confidence intervals (CI).

RESULTS

We identified five SDH classes: Class 1: no SDH adversities; Class 2: mainly unemployment; Class 3: low education and unemployment; Class 4: sexual violence and unemployment; and Class 5: multiple SDH adversities. The prevalence of last-month drug use ranged from 7.0% in Class 1 to 53.3% in Class 5. Compared to FSWs in Class 1, those in Class 2 (aPR: 2.47, 95% CI: 1.15, 5.27), Class 3 (aPR: 3.69, 95% CI: 1.62, 8.36), Class 4 (aPR: 4.49, 95% CI: 1.71, 11.78) and Class 5 (aPR: 6.35, 95% CI: 2.42, 16.69) were more likely to report last-month drug use. The same patterns were observed for specific drugs of opium use, crystal methamphetamine use, and heroin-crack use, as well as poly-drug use.

CONCLUSION

Socio-structural determinants are clustered together and elevate the likelihood of illicit drug use among FSWs. Our findings highlighted the significance of assessing and addressing such key determinants of health in drug use harm reduction programs targeting FSWs.

Microfinance and violence prevention: A review of the evidence and adaptations for implementation in the U.S

Microfinance programs provide access to small amounts of capital in the form of credit, savings, or financial incentives. There is evidence that microfinance reduces financial strain and reduces violence making it a promising public health approach. However, most of this evidence was generated internationally in low-resource countries; thus, it is likely that adaptations are necessary for microfinance to be effective at preventing violence in the U.S. This article reviews the evidence base for microfinance interventions on violence outcomes; outlines the potential of microfinance to prevent violence in the U.S.; and offers some possible adaptations in order to increase the likelihood that microfinance will prevent violence in the U.S. Programs might consider providing matched savings instead of small loans to individuals and providing job skills training. Furthermore, it is important for U.S. microfinance programs to engage multiple sectors and to consider additional content, such as a gender equity component and safety planning to protect those who might be in violent relationships. It is also important that these adaptations be rigorously evaluated for impacts on multiple forms of violence.

Drugs, discipline and death: Causes and predictors of mortality among people who inject drugs in Tijuana, 2011-2018

BACKGROUND

People who inject drugs (PWID) experience multiple risk factors for mortality; yet, we know little about causes of death among PWID in Tijuana, Mexico, an area with high levels of injecting and changes in policy/law enforcement responses to substance use. This study examines rates, causes, and predictors of mortality among Tijuana PWID.

METHODS

Data come from a community-based cohort of PWID aged ≥18 who injected drugs in the past month. Mortality was confirmed by death certificate over 78 months during 2011-2018. Predictors of mortality were identified using time-updated Cox regression, controlling for age.

RESULTS

Among 734 participants, there were 130 deaths (54 confirmed, 76 unconfirmed), with an incidence rate of 17.74 deaths per 1000 person-years for confirmed deaths (95% Confidence Interval (CI)=13.01, 22.48) and 39.52 for unconfirmed deaths (CI=32.72, 46.31). Confirmed deaths resulted from homicide/trauma (26%), overdose (26%), septic shock (18%) and HIV-related causes (9%). In multivariable analysis of confirmed deaths, baseline HIV seropositivity (adjusted Hazard Ratio [aHR]=6.77, CI=1.98, 23.17), incident HIV infection (aHR=3.19, CI=1.02, 9.96), and number of times being beaten by police in the past 6 months at baseline (aHR=1.08 per time, CI=1.04, 1.12) were predictive of death; whereas, injection cessation for 6+ months during time at risk (aHR=0.25, CI=0.33, 0.79) was protective.

CONCLUSION

In addition to overdose and HIV prevention efforts, attention to structural conditions that potentiate mortality is needed, including improved access to medication-assisted treatment to support injection cessation and a shift from police as a source of harm to harm reduction.

Employment Cessation, Long Term Labour Market Engagement and HIV Infection Risk Among People Who Inject Drugs in an Urban Canadian Setting

The potential for changes in socio-economic status, such as employment exits, to increase HIV infection risk are not well examined among people who inject illicit drugs (PWID). We used longstanding cohort data from Vancouver, Canada, to longitudinally assess associations between employment cessation and outcomes with documented linkages to HIV infection risk among PWID. From 2005 to 2015, 1222 participants reported 1154 employment exits. Employment exits were significantly associated with transitions into unstable housing; moving to the inner-city; initiating informal, prohibited or illegal income generation; high risk drug use practices; and exiting methadone maintenance therapy. HIV infection rates were higher among participants with lower long-term labour market engagement. These findings suggest that employment cessation coincides with initiating exposure to aspects of socioeconomic marginalization and drug use associated with HIV infection risk. Support for employment retention that prevents poverty entrenchment and harmful drug use could contribute to HIV prevention measures for PWID.

Prevalence and risk factors of HIV infection among people who inject drugs in Cambodia: findings from a national survey

BACKGROUND

Globally, people who inject drugs (PWID) continue to be among the most vulnerable populations to acquire infection of human immunodeficiency virus (HIV). The most recent national survey found that nearly a quarter of PWID in Cambodia were infected with HIV in 2012. The aim of this study is to estimate the current prevalence of and factors associated with HIV infection among PWID in Cambodia.

METHODS

This national integrated biological and behavioral survey was conducted from June to December 2017. Participants were recruited from the capital city and 11 major provinces using the respondent driven sampling method. Face-to-face interviews were conducted using a structured questionnaire, and blood samples were collected for HIV, syphilis, and hepatitis C virus (HCV) testing. Multiple logistic regression analysis was conducted to identify risk factors for HIV infection. All analyses were estimated with sampling weights that corrected for non-response and sample design.

RESULTS

A total of 310 PWID participated in the study, and the mean age was 31.8 years (SD = 7.8). The prevalence of HIV was 15.2%. More than half (57.4%) of the HIV-positive participants were co-infected with HCV, and 44.7% were not aware of their HIV status prior to this study. After adjustment for other covariates, HIV infection remained positively associated with being female (AOR = 1.88, 95% CI = 1.03-4.04), being in the older age group of ≥35 (AOR = 2.99, 95% CI 1.33-9.22), being widowed, divorced or separated (AOR = 2.57, 95% CI = 1.04-6.67), living on the streets (AOR = 2.86, 95% CI 1.24-4.37), and HCV infection (AOR = 3.89, 95% CI 1.86-1.15). The HIV infection remained negatively associated with having higher level of formal education of ≥10 years (AOR = 0.44, 95% CI 0.13-0.83) and higher average income of ≥US$200 per month (AOR = 0.20, 95% CI = 0.05-0.74).

CONCLUSIONS

The prevalence of HIV among PWID in Cambodia remains high, but is reducing compared with the 24.8% reported in the 2012 national survey. Findings from this study provide critical information for tailoring interventions based on identified vulnerabilities and risk factors for HIV. Our findings underline the importance of socio-structural factors in HIV epidemiology among PWID in Cambodia, which require mitigation.

Perceived Value of Microenterprise for Low-Income Women Living with HIV in Alabama

We characterized the potential benefits and risks of participating in a microenterprise program targeting low-income women living with HIV (WLWH) in Alabama; and described potential mechanisms through which microenterprise programs could influence sexual risk behaviors and engagement in HIV care. Fourteen stakeholders and 46 WLWH (89% African American) participated in the qualitative study. Data were collected using in-depth interviews (stakeholders) and focus group discussions (WLWH). NVivo qualitative software was used for the management and analysis of the data. The data revealed four main mechanisms through which microenterprise programs could potentially improve health outcomes: (1) social support and encouragement from other women, (2) improvement in self-esteem, (3) creating structure in the women's lives, and (4) financial strengthening. Potential risks included unwanted disclosure of HV status, stigma and loss of insurance benefits. Microenterprise programs have the potential to be acceptable and may contribute to improved health and social outcomes among low-income WLWH in Alabama.

A combination intervention addressing sexual risk-taking behaviors among vulnerable women in Uganda: study protocol for a cluster randomized clinical trial

BACKGROUND

Sub-Saharan Africa (SSA) has the highest number of people living with HIV/AIDS, with Nigeria, South Africa, and Uganda accounting for 48% of new infections. A systematic review of the HIV burden among women engaged in sex work (WESW) in 50 low- and middle-income countries found that they had increased odds of HIV infection relative to the general female population. Social structural factors, such as the sex work environment, violence, stigma, cultural issues, and criminalization of sex work are critical in shaping sexually transmitted infection (STI)/HIV risks among WESW and their clients in Uganda. Poverty is the most commonly cited reason for involvement in sex work in SSA. Against this backdrop, this study protocol describes a randomized controlled trial (RCT) that tests the impact of adding economic empowerment to traditional HIV risk reduction (HIVRR) to reduce new incidence of STIs and HIV among WESW in Rakai and the greater Masaka regions in Uganda.

METHODS

This three-arm RCT will evaluate the efficacy of adding savings, financial literacy and vocational training/mentorship to traditional HIVRR on reducing new incidence of STI infections among 990 WESW across 33 hotspots. The three arms (n = 330 each) are: 1) Control group: only HIVRR versus 2) Treatment group 1: HIVRR plus Savings plus Financial Literacy (HIVRR + S + FL); and 3) Treatment group 2: HIVRR plus S plus FL plus Vocational Skills Training and Mentorship (V) (HIVRR + S + FL + V). Data will be collected at baseline (pre-test), 6, 12, 18 and 24-months post-intervention initiation. This study will use an embedded experimental mixed methods design where qualitative data will be collected post-intervention across all conditions to explore participant experiences.

DISCUSSION

When WESW have access to more capital and/or alternative forms of employment and start earning formal income outside of sex work, they may be better able to improve their skills and employability for professional advancement, thereby reducing their STI/HIV risk. The study findings may advance our understanding of how best to implement gender-specific HIV prevention globally, engaging women across the HIV treatment cascade. Further, results will provide evidence for the intervention's efficacy to reduce STIs and inform implementation sustainability, including costs and cost-effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov , ID: NCT03583541 .

Microenterprise intervention to reduce sexual risk behaviors and increase employment and HIV preventive practices in economically-vulnerable African-American young adults (EMERGE): protocol for a feasibility randomized clinical trial

Background

Economic vulnerability, such as homelessness and unemployment, contributes to the HIV risk among racial minorities in the U.S., who are disproportionately infected. Yet, few economic-strengthening interventions have been adapted for HIV prevention in economically-vulnerable African-American young adults. Engaging Microenterprise for Resource Generation and Health Empowerment (EMERGE) is a feasibility randomized clinical trial of an HIV prevention microenterprise intervention with integrated text messages (“nudges”) that are informed by behavioral economic principles. The trial aims to reduce sexual risk behaviors and increase employment and uptake of HIV preventive behaviors.

Methods/design

In total, 40 young adults who are African-American, aged 18–24, live in Baltimore City, have experienced at least one episode of homelessness in the last 12 months, are unemployed or underemployed (fewer than 10 h per week), are not enrolled in school, own a cell phone with text messaging, and report at least one episode of unprotected or unsafe sex in the prior 12 months will be recruited from two community-based organizations providing residential supportive services to urban youth. Participants will undergo a 3-week run-in period and thereafter be randomly assigned to one of two groups with active interventions for 20 weeks. The first group (“comparison”) will receive text messages with information on job openings. The second group (“experimental”) will receive text messages with information on job openings plus information on HIV prevention and business educational sessions, a mentored apprenticeship, and a start-up grant, and business and HIV prevention text messages based on principles from behavioral economics. The two primary outcomes relate to the feasibility of conducting a larger trial. Secondary outcomes relate to employment, sexual risk behaviors, and HIV preventive practices. All participants will be assessed using an in-person questionnaire at pre-intervention (prior to randomization) and at 3 weeks post-intervention. To obtain repeated, longitudinal measures, participants will be assessed weekly using text message surveys from pre-intervention up to 3 weeks post-intervention.

Discussion

This study will be one of the first U.S.-based feasibility randomized clinical trials of an HIV prevention microenterprise intervention for economically-vulnerable African-American young adults. The findings will inform whether and how to conduct a larger efficacy trial for HIV risk reduction in this population.

Trial registration

ClinicalTrials.gov, NCT03766165. Registered on 4 December 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3529-7) contains supplementary material, which is available to authorized users.

Role of boyfriends and intimate sexual partners in the initiation and maintenance of injecting drug use among women in coastal Kenya

INTRODUCTION

Gender dynamics and interpersonal relations within intimate partnerships are known to determine health behaviors, including substance use, within couples. In addition, influence from intimate partners may occur in the context of wider social ecological determinants of health behavior. The aim of this study was to document the role of intimate partners in influencing injecting drug use among women in Kenya, where injecting drug use is on the rise.

METHODS

We performed secondary data analysis of an existing dataset from a 2015 qualitative study involving 45 women who inject drugs and 5 key stakeholders in coastal Kenya. Primary data had been collected via a combination of in-depth interviews and focus group discussions exploring sexual, reproductive, drug use, and other social contexts of women who inject drugs. The process by which intimate partners influenced women's initiation of drug use, transition to injecting practices, and maintenance of injecting drug use were identified using thematic analysis.

RESULTS

Boyfriends and intimate either facilitated or restrained women's drug-injecting. On the one hand, young women's entry into drug use was prompted by relationship problems, or a need to acquiesce with their drug-using boyfriends. Once women started injecting, intimate partners facilitated ongoing drug-injecting by financing the acquisition of drugs, peddling drugs to their women, or sharing their drugs with their women. The social capital that peddlers held insulated women from police arrests, and encouraged women to seek and sustain intimate relations with well-connected peddlers. Men's influences over women were driven by an underlying patriarchal drug acquisition and economic power. On the other hand, boyfriends and intimate partners who were non-injectors or non-drug users sought to moderate women's injecting drug use by encouraging them to inject less, to smoke or snort instead of injecting, or to enroll into rehabilitation. These moderating influences were most prominent when couples were pregnant. Despite men being a source of practical and emotional support, women were frequently unable limit or alter their injecting drug use, due to its addictive nature. Men's disagreement with women's ongoing injecting strained relationships, and occasionally led to separation.

CONCLUSIONS

Some boyfriends facilitated women's injecting drug use, while others moderated it, supporting assertions that intimate relationships can both be a site of injecting risks or protection. At the micro-level, these findings highlight an opportunity for couple-based interventions, leveraging on non-drug injecting males as a resource to support women adopt safer injecting practices. At a macro level, incorporating livelihood interventions into harm reduction programs is required in order to mitigate economic-based influence of male intimate partners on women's injecting drug use. At both levels, gender transformative approaches are essential. To gain a comprehensive understanding of women's injecting drug use, future studies drug use should explore women's contexts beyond micro influences and consider their wider macro-structural determinants.

Cluster randomized stepped-wedge trial of a multi-level HIV prevention intervention to decrease amphetamine-type stimulants and sexual risk in Cambodian female entertainment and sex workers

BACKGROUND

HIV prevention for female entertainment and sex workers (FESW) may be optimized by addressing individual and structural risks. We examined the impact of a sequentially delivered intervention to decrease sexual risk, amphetamine-type stimulant (ATS) use, and improve economic well-being in Cambodian FESW.

METHODS

A cluster randomized stepped-wedge trial was conducted in 10 Cambodian provinces to test multi-level intervention in high risk FESW. After baseline screening in 1198 women, those screening positive for ATS use disorder were allocated to a 12-week conditional cash transfer intervention followed by a 4-week cognitive-behavioural aftercare group (CCT + AC). At six months, ATS abstinent participants were offered a microenterprise (ME) opportunity. Co-primary outcomes assessed in 600 FESW at each 6-, 12- and 18-month follow-up assessments, included: 1) number of sexual partners (past three months); and 2) ATS urine toxicology positive (Tox+) results. Secondary outcomes included indicators of economic well-being.

RESULTS

Relative to baseline, FESW reported fewer sexual partners at all follow-up assessments with a significant 50% decrease at 12-months (Adjusted Rate Ratio [ARR] = 0.50; 95%CI: 0.25, 0.95). Women had 60% lower odds of being ATS Tox+ (Adjusted Odds Ratio [AOR] = 0.40; 95%CI: 0.25, 0.65) at 6-months, and continued but non-significant reductions at 12- and 18-months. Improvements in economic well-being indicators were observed at 12- and 18-months.

CONCLUSIONS

Findings support the robust effectiveness of the sequentially delivered CCT + AC and ME interventions for boosting HIV prevention for Cambodian FESW. Further research is needed to inform the scale up and improve durability of this comprehensive approach with FESW in Southeast Asia.

HIV risk behaviours among women who inject drugs in coastal Kenya: findings from secondary analysis of qualitative data

Background

Injecting drug users are at high risk of HIV infection globally. Research related to female drug users is rare in Kenya, yet it is required to inform the development of gender-sensitive HIV prevention and harm reduction services in East Africa, where injecting drug use is on the rise.

Methods

This study aimed to document the nature of HIV risks encountered by women who inject drugs in the Mombasa and Kilifi, Kenya. Secondary data analysis was conducted on an existing dataset from a 2015 primary qualitative study involving 24 interviews and 3 focus group discussions with 45 women who inject drugs. These were complemented with five interviews with key stakeholders involved in the provision of services to women who inject drugs. Guided by the social ecology theory, a thematic analysis was conducted to identify the nature of HIV risks and their underlying determinants.

Results

HIV risk behaviours fell into two broad categories: unsafe injecting and unprotected sex. These risks occurred in the form of sharing of needles, unprotected oral, anal, and vaginal sex, sexual assaults, injecting drug use during sex, sex work, and other types of transactional sex. The primary determinants underlying these risks were a low-risk perception, inequitable gender power, economic pressures, and poor availability of needles and condoms. These social-ecological determinants did not exist in isolation, but intersected with each other to create powerful influences which exposed women to HIV. Social-ecological determinants exerted constant influence and created a persistent ‘HIV risk environment’ that was involuntarily experienced by women.

Conclusion

Individual, interpersonal, and societal-structural factors intersect to produce HIV risk behaviours. As a minimum, these risks will require a combination of multifaceted micro-level interventions including self-efficacy training, risk assessment skills, couple counselling, and universal access to the recommended harm reduction package. In addition, the current focus on micro-level interventions in Kenya needs to shift to incorporate macro-level interventions, including livelihood, employability, and gender norms-transforming interventions, to mitigate economic and gender-related drivers of HIV risks. In the Kenyan context, injecting drug use during sex work is emerging as an increasingly important HIV risk behaviour needing to be addressed.

Project Nova: A Combination HIV Prevention and Microfinance Intervention for Women Who Engage in Sex Work and Use Drugs in Kazakhstan

Innovative combination HIV-prevention and microfinance interventions are needed to address the high incidence of HIV and other STIs among women who use drugs. Project Nova is a cluster-randomized, controlled trial for drug-using female sex workers in two cities in Kazakhstan. The intervention was adapted from prior interventions for women at high risk for HIV and tailored to meet the needs of female sex workers who use injection or noninjection drugs. We describe the development and implementation of the Nova intervention and detail its components: HIV-risk reduction, financial-literacy training, vocational training, and a matched-savings program. We discuss session-attendance rates, barriers to engagement, challenges that arose during the sessions, and the solutions implemented. Our findings show that it is feasible to implement a combination HIV-prevention and microfinance intervention with highly vulnerable women such as these, and to address implementation challenges successfully.

Structural interventions and social suffering: Responding to amphetamine-type stimulant use among female entertainment and sex workers in Cambodia

BACKGROUND

In Cambodia, HIV infection remains high among female entertainment and sex workers (FESW) and the use of amphetamine-type stimulants (ATS) is an independent risk factor for unprotected sex and sexually transmitted infections among this group. For decades public health approaches to HIV prevention in low and middle income countries (LMIC) have attempted to target the macro-power relations that shape risk behaviour with structural interventions. Recent research has highlighted that interventions that combine ATS risk reduction, in the form of financial incentives for abstinence, with existing HIV prevention programmes, may also play an important role. However, whether this approach goes far enough as a response to structural drivers of risk requires further examination.

METHODS

Semi-structured in-depth interviews were conducted with 30 FESW (mean age 25 years) from five provinces in Cambodia, as part of formative research for the implementation of the Cambodia Integrated HIV and Drug Prevention (CIPI) trial. The aim was to explore the contexts and drivers of ATS use. Data were analysed using grounded theory.

RESULTS

In addition to increasing occupational functionality, ATS were used to control pervasive feelings of 'sadness' in relation to the lived experience of poverty, family and relationship problems. Feeling sad could be viewed as an expression of social suffering, in response to competing priorities and seemingly inescapable constraints imposed by a lack of options for income generation, gender inequalities and stigma. Participants expressed interest in microenterprise (ME) opportunities, particularly vocational training, that could create new work opportunities beyond sex work and ATS use.

CONCLUSION

In addition to reducing ATS use, HIV prevention interventions need to target sources of sadness and social suffering as drivers of risk among FESW in this context. The inclusion of ME opportunities in HIV prevention, to alleviate social suffering, warrants further investigation through qualitative and ethnographic research.

Intimate partner violence and receptive syringe sharing among women who inject drugs in Indonesia: A respondent-driven sampling study

BACKGROUND

Intimate partner violence (IPV) and HIV are overlapping public health problems that disproportionately affect women who inject drugs. Little is known about the relationship between IPV and HIV-related unsafe injecting practices among women in low- and middle-income settings. This study investigated whether IPV victimisation was associated with receptive syringe sharing among women who inject drugs in Indonesia.

METHODS

Respondent-driven sampling (RDS) was used to recruit 731 women aged 18+ years, injecting drugs in the preceding 12 months, and residing in Greater Jakarta or Bandung, West Java. Population estimates were derived using the RDS-II estimator. Multivariate logistic regressions assessed relationships between different forms of past-year IPV (i.e. psychological abuse, physical and/or injurious assault, forced sex) and receptive syringe sharing, controlling for city differences and sociodemographic cofactors.

RESULTS

Overall, 21.1% of participants reported engaging in past-month receptive syringe sharing. In multivariate analyses controlling for all forms of IPV, receptive syringe sharing was significantly positively associated with experiencing psychological abuse (OR = 1.86; 95% CI = 1.06,3.24; p = 0.030), physical and/or injurious assault (OR = 1.73; 95% CI = 1.04,2.89; p = 0.034), and several covariates: injecting pharmaceuticals only (versus heroin only) (OR = 3.58; 95% CI = 1.66,7.69; p = 0.001), experiencing unstable housing and/or homelessness (OR = 2.89; 95% CI = 1.41,5.95; p = 0.004), and residing in Bandung, West Java (versus Greater Jakarta) (OR = 2.33; 95% CI = 1.40,3.90; p = 0.001).

CONCLUSION

IPV is a significant risk factor for HIV-related injecting risk among women who inject drugs in Indonesia. These findings indicate the urgent need to scale up harm reduction interventions and align existing programs with IPV prevention and support services, with specific efforts targeting the needs of female injectors.

Drug use in street sex workers (DUSSK) study protocol: a feasibility and acceptability study of a complex intervention to reduce illicit drug use in drug-dependent female street sex workers

INTRODUCTION

Poor health of sex workers continues to be a source of international concern. Sex work is frequently linked with problematic drug use and drug-dependent sex workers typically work on the street, experiencing the greatest risks to health compared with the general population. Street sex workers (SSWs) are much more likely to have experienced incidences of physical and sexual assault, increasing their risk of developing post-traumatic stress disorder (PTSD). We have developed a novel complex intervention designed to reduce illicit drug use in drug-dependent female SSWs which involves: female SSW drug treatment groups (provided by a specialist charity) in a female SSW setting (female sex worker charity premises) provided by female-only staff, PTSD care with eye movement desensitisation and reprocessing (EMDR) therapy provided by female staff from National Health Service (NHS) mental health services.

METHODS AND ANALYSIS

A mixed methods study investigating the feasibility and acceptability of this intervention to inform the design of a future randomised controlled trial. The study aims to recruit up to 30 participants from November 2017 to March 2018 at a single site, with the intervention being delivered until December 2018. It will gather quantitative data using questionnaires and group attendance. Drug treatment group observations and in-depth interviews undertaken with up to 20 service users and 15 service providers to examine experiences and acceptability of the intervention. Study feasibility will be assessed by evaluating the recruitment and retention of participants to the intervention; the feasibility of NHS and third sector organisations working closely to coordinate care for a SSW population; the potential for specialist NHS mental health services to screen and provide EMDR therapy for drug-dependent SSWs and potential costs of implementing the intervention.

ETHICS AND DISSEMINATION

This study was approved by South West-Frenchay Research Ethics Committee (REC reference: 17/SW/0033; IRAS ID: 220631) and the Health Research Authority (HRA). Findings will be disseminated through research conferences and peer-reviewed journals.

Interventions that Address Intimate Partner Violence and HIV Among Women: A Systematic Review

Recognizing the high prevalence of human immunodeficiency virus (HIV)-positive women and girls who are either at risk for or suffer from intimate partner violence (IPV) and the overlapping challenges posed by both public health issues, the White House established an Interagency Federal Working Group to address the intersection of both public health issues in 2012. We conducted this systematic review in response to the Working Group's charge to identify and describe interventions that address both IPV and HIV among women. We identified 14 studies that met our inclusion criteria, including seven studies (nine unique intervention arms) that significantly affected at least one outcome related to IPV and HIV. In this article, we examine the characteristics of these studies including core components, intervention populations, and effectiveness data. We highlight opportunities to improve the effectiveness of existing interventions, guide future research about IPV and HIV, and inform prevention programmatic delivery. This knowledge will improve the lives of populations at risk, reduce gender-related health disparities, and ultimately reduce the societal burden of both public health issues.

Women and HIV in the Twenty-First Century: How Can We Reach the UN 2030 Goal?

Women have always been part of the HIV/AIDS epidemic. As with other populations affected by HIV, for many years the only prevention strategy available was behavior change. Behavioral interventions for women were developed and evaluated, with some success. Because women did not control the use of male condoms, efficacious interventions needed to build skills for partner negotiation. Woman-controlled technologies such as the female condom and vaginal spermicide were unable to solve the problem of male control of the condom and enable the development of safe methods for women to protect themselves. The modern era of HIV prevention has produced biomedical solutions based on highly active retroviral chemoprophylaxis, which can be hidden from the male partner and thus eliminate his possible negative reactions. Pre-exposure prophylaxis holds promise for HIV prevention among women. This article reviews the literature on HIV prevention for women, including both successes and challenges.

Microfinance for women at high risk for HIV in Kazakhstan: study protocol for a cluster-randomized controlled trial

BACKGROUND

Among women at high risk for HIV and other sexually transmitted diseases (STIs), gender and economic issues limit the impact of behavioral prevention strategies. Women in Kazakhstan with dual risks of sex trading and drug use face elevated risk for HIV and STIs and may benefit from an economic empowerment intervention which combines HIV-risk reduction (HIVRR) education with financial skills-building and asset-building to promote reduced reliance on sex trading for income.

METHODS/DESIGN

The study employs a two-arm, cluster-randomized controlled trial (c-RCT) design. We will use cluster randomization to assign 350 women in approximately 50 cohorts to a traditional four-session HIV-risk-reduction intervention combined with a six-session financial literacy intervention, enrollment in a 24-session vocational training program and receipt of matched savings (HIVRR+MF); or to the four-session HIV-risk-reduction intervention alone (HIVRR). Repeated behavioral and biological assessments will be conducted at baseline, then at 6, 9, and 15 months post randomization/session 1.

DISCUSSION

This study responds to an identified need in the academic literature for rigorous testing of structural interventions, including combination microfinance and HIV-prevention interventions.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02406482 . Registered on 30 March 2015.

A Qualitative Investigation of the Impact of a Livelihood Intervention on Gendered Power and Sexual Risk Behaviors Among HIV-Positive Adults in Rural Kenya

Despite the recognized links between food insecurity, poverty, and the risk of HIV/AIDS, few randomized trials have evaluated the impact of livelihood interventions on HIV risk behaviors. The current study draws upon data collected from a qualitative process evaluation that was embedded into a pilot randomized controlled trial that tested whether a multisectoral agricultural intervention (Shamba Maisha) affected the HIV-related health of HIV-positive adults in rural Kenya. In the current study, we drew upon longitudinal, in-depth interviews with 45 intervention participants and nine control participants (N = 54) in order to examine the impacts of the intervention on gendered power and sexual risk reduction among both women and men. Female and male participants in the intervention described positive changes in sexual practices and gendered power dynamics as a result of intervention participation. Changes included reduced sexual risk behaviors, improved gender-related power dynamics, and enhanced quality of intimate relationships. These findings illuminate how a multisectoral agricultural intervention may affect inequitable gender relations and secondary transmission risk. Further research is needed to explore how to best leverage agricultural interventions to address the important intersections between poverty and inequitable gender relations that shape HIV risks.

A global comprehensive review of economic interventions to prevent intimate partner violence and HIV risk behaviours

BACKGROUND

Intimate partner violence (IPV) and HIV are co-occurring global epidemics, with similar root causes of gender and economic inequalities. Economic interventions have become a central approach to preventing IPV and HIV.

OBJECTIVE/METHODS

We undertook a comprehensive scoping review of published evaluations of economic interventions that sought to prevent IPV and/or HIV risk behaviours.

RESULTS

Forty-five separate analyses of interventions met our criteria. Broadly, unconditional cash transfer interventions showed either flat or positive outcomes; economic strengthening interventions had mixed outcomes, with some negative, flat and positive results reported; interventions combining economic strengthening and gender transformative interventions tended to have positive outcomes.

CONCLUSIONS

The review highlighted a number of gaps. Specifically, there were limited studies evaluating the impact of economic interventions on female sex workers, young women, and men. In addition, there were missed opportunities, with many evaluations only reporting either IPV- or HIV-related outcomes, rather than both, despite overlaps.

Income generation and attitudes towards addiction treatment among people who use illicit drugs in a Canadian setting

INTRODUCTION

Socioeconomically marginalized people who use illicit drugs (PWUD) often engage in alternative income generating activities to meet their basic needs. These activities commonly carry a number of health and social risks, which may prompt some PWUD to consider addiction treatment to reduce their drug use or drug-related expenses. We sought to determine whether engaging in certain forms of income generation was independently associated with self-reported need for addiction treatment among a cohort of PWUD in Vancouver, Canada.

METHODS

Data from two prospective cohorts of PWUD in Vancouver were used in generalized estimating equations to identify factors associated with self-reported need for addiction treatment, with a focus on income generating activities.

RESULTS

Between June 2013 and May 2014, 1285 respondents participated in the study of whom 483 (34.1%) were female and 396 (30.8%) indicated that they needed addiction treatment. In final multivariate analyses, key factors significantly and positively associated with self-reported need for addiction treatment included engaging in illegal income generating activities (adjusted odds ratio [AOR]=1.96, 95% confidence interval [CI}: 1.11-3.46); sex work (AOR=1.61, 95% CI: 1.05-2.47), homelessness (AOR=1.65, 95% CI: 1.22-2.25); and recent engagement in counselling (AOR=1.85, 95% CI: 1.40-2.44).

DISCUSSION

Our results suggest that key markers of socioeconomic marginalization are strongly linked with a stated need for addiction treatment. These findings underscore the need to provide appropriate and accessible addiction treatment access to marginalized PWUD and to consider alternative approaches to reduce socioeconomic disadvantage.

The impact of a microsavings intervention on reducing violence against women engaged in sex work: a randomized controlled study

Background

Women who engage in sex work are at risk for experiencing violence from numerous perpetrators, including paying partners. Empirical evidence has shown mixed results regarding the impact of participation in microfinance interventions on women’s experiences of violence, with some studies demonstrating reductions in intimate partner violence (IPV) and others showing heightened risk for IPV. The current study reports on the impact of participation in a microsavings intervention on experiences of paying partner violence among women engaged in sex work in Mongolia.

Methods

Between 2011 and 2013, we conducted a two-arm, non-blinded randomized controlled trial (RCT) comparing an HIV/STI risk reduction intervention (HIVSRR) (control condition) to a combined microsavings and HIVSRR intervention (treatment condition). Eligible women (aged 18 or older, reported having engaged in unprotected sex with paying partner in past 90 days, expressed interest in microsavings intervention) were invited to participate. One hundred seven were randomized, including 50 in the control and 57 in the treatment condition. Participants completed assessments at baseline, immediate post-test following HIVSRR, and at 3-months and 6-months after completion of the treatment group intervention. Outcomes for the current study include any violence (physical and/or sexual), sexual violence, and physical violence from paying partners in the past 90 days.

Results

An intention-to-treat approach was utilized. Linear growth models revealed significant reductions over time in both conditions for any violence (β = −0.867, p < 0.001), physical violence (β = −0.0923, p < 0.001), and sexual violence (β = −1.639, p = 0.001) from paying partners. No significant differences between groups were found for any violence (β = 0.118, p = 0.389), physical violence (β = 0.091, p = 0.792), or sexual violence (β = 0.379, p = 0.114) from paying partners.

Conclusions

Microsavings participation did not significantly impact women’s risk for paying partner violence. Qualitative research is recommended to understand the cause for reductions in paying partner violence in both study conditions.

Trial registration

Evaluating a Microfinance Intervention for High Risk Women in Mongolia; NCT01861431; May 20, 2013.

Plasma HIV-1 RNA viral load rebound among people who inject drugs receiving antiretroviral therapy (ART) in a Canadian setting: an ethno-epidemiological study

Background

People who inject drugs (PWID) living with HIV often experience sub-optimal antiretroviral therapy (ART) treatment outcomes, including HIV plasma viral load (PVL) rebound. While previous studies have identified risk factors for PVL rebound among PWID, no study has examined the perspectives of PWID who have experienced PVL rebound episodes. We conducted an ethno-epidemiological study to investigate the circumstances surrounding the emergence of rebound episodes among PWID in Vancouver, BC, Canada.

Methods

Comprehensive clinical records linked to a community-based prospective observational cohort of HIV-positive drug users were used to identify PWID who had recently experienced viral rebound. In-depth qualitative interviews with 16 male and 11 female participants explored participant perspectives regarding the emergence of viral rebound. A timeline depicting each participant’s HIV viral load and adherence to ART was used to elicit discussion of circumstances surrounding viral rebound.

Findings

Viral rebound episodes were shaped by interplay between various individual, social, and environmental factors that disrupted routines facilitating adherence. Structural-environmental influences resulting in non-adherence included housing transitions, changes in drug use patterns and intense drug scene involvement, and inadequate care for co-morbid health conditions. Social-environmental influences on ART adherence included poor interactions between care providers and patients producing non-adherence, and understandings of HIV treatment that fostered intentional treatment discontinuation.

Conclusions

This study describes key pathways which led to rebound episodes among PWID receiving ART and illustrates how environmental forces may increase vulnerability for non-adherence leading to treatment failure. Our findings have potential to help inform interventions and supports that address social-structural forces that foster non-adherence among PWID.

Ithubalethu-Intervention to Address Drug Use and Sexual HIV Risk Patterns among Female Commercial Sex Workers in Durban, South Africa

Previous research shows that interventions aimed at female sex workers (FSWs) can be successful in reducing HIV risk behavior. The current study evaluated a specific HIV prevention intervention for substance-using FSWs in Durban, South Africa by comparing such behaviors before and after the intervention. The intervention was provided by trained outreach workers by an organization that worked with FSWs, and consisted of community-based outreach, HIV and substance use education and information. Safer sex practices were also taught. The sample consisted of 457 substance-using FSWs, with findings indicating a significant decrease in the number of sexual partners (z = -16.05, p < 0.001), number of times they engaged in vaginal sex (z = -8.07, p < 0.001), and a significant decrease in all substances used with the exception of over-the-counter or prescription substances. The intervention therefore seemed to reduce certain risk behaviors among this group of FSWs. Future research should focus on the aspects of the substance use-sex risk intervention that were associated with decreased risk behavior, and include a randomized controlled trial to assess effectiveness of the intervention.