Search

Abstract Background Economic vulnerability influences women engaged in commercial sex work (WESW) to further engage in sexual risk behaviors, as they often have multiple customers and engage in unprotected sex for financial gains. This study examined asset ownership’s direct and indirect impact on sexual risk-taking behaviors among WESW in Southern Uganda, a very vulnerable group of women at high risk for contracting HIV and other STIs. Methodology We used baseline data from the Kyaterekera study, an NIH-funded study among WESW aged 18–55 across 19 HIV hotspots in Southern Uganda. Structural equation modeling was used to examine the direct, indirect, and total effects of assets—defined as ownership of physical and financial resources—on sexual risk-taking behaviors among WESW. Results Results showed that asset ownership was associated with a decrease in depression (β = − 0.096 [95% CI − 0.191, − 0.001], p = 0.050) and increased access to medical care (β = 0.174 [95% CI 0.072, 0.275], p = 0.001).We also found that an increase in access to medical care was associated with decreased sexual risk-taking behaviors (β = − 0.107 [95% CI − 0.210, − 0.004], p = 0.041). We observed a specific indirect effect between assets and sexual risk-taking behaviors through access to medical care (β = − 0.019 [95% CI − 0.040, − 0.002], p = 0.05). Mediation contributed 31% of the total effects of asset ownership on sexual risk-taking behaviors. Conclusion To our knowledge, this is among the few studies to examine the impact of asset ownership on sexual risk-taking behaviors among WESW in Southern Uganda. Findings from this study indicate that increasing access to economic resources may reduce the risk of WESW engaging in unprotected sex for higher income, which limits the spread of HIV among this population. The results also indicate that asset ownership may allow women to access healthcare services.

Abstract Background The global HIV burden remains a public health concern. Women engaged in sex work (WESW) are at higher risk of acquiring HIV compared to the general adult population. Uganda reports high rates of HIV prevalence among WESW. While WESW in Uganda have long been the subject of surveillance studies, they have not been targeted by theory-informed HIV prevention intervention approaches. In this study, we explored the perceived benefits of an evidence-based HIV risk reduction intervention that was implemented as part of a combination intervention tested in a clinical trial in Uganda. Methods As part of a larger randomized clinical trial, we conducted semi-structured in-depth interviews with 20 WESW selected using a stratified purposive sampling. All interviews were conducted in Luganda, language spoken in the study area, and audio-recorded. They were transcribed verbatim and translated to English. Thematic analysis was used to analyze the data. Results WESW’s narratives focused on: (1) condom use; (2) alcohol/drug consumption; (3) PrEP use; (4) “handling” customers; and (5) "massaging” customers. WESW agreed that male condom was one of the important learning points for them and planned to continue using them while female condoms were received with mixed reactions. Many women appreciated receiving information about the risks of consuming alcohol and drugs, and discussed how they reduced/ eliminated their consumption. PrEP information was appreciated though identified by fewer WESW. Handling a client was discussed as a helpful strategy for safer sex through improved ability to convince customers to use condoms or avoiding sex. Massaging was also beneficial to avoid penetrative sex, but similar to female condom, massaging also yielded mixed perceptions. Conclusion WESW found the intervention beneficial and described ways in which it improved their ability to engage in safer sex and stay healthy. The fact that WESW identified other strategies beyond condom use as helpful underlines the importance of adopting a comprehensive approach to behavioral interventions targeting HIV prevention even when combined with other interventions. Additionally, WESW’s narratives suggest that incorporating the tenets of social cognitive theory and harm reduction approaches in HIV prevention among this population can result in risk behavior change.

Abstract 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.