RESUMEN
Poverty and economic insecurity are driving forces in entering sex work among women in low resource areas. This increases their risk for HIV by influencing the decision-making process for high-risk behaviors. Few studies examine financial behaviors and capacities of women engaged in sex work (WESW). This paper describes the methodology used in a financial diary study aimed at characterizing women's spending patterns within a larger prevention intervention trial among WESW in Uganda. From June 2019 to March 2020, a subsample of 150 women randomized to the combination HIV prevention and economic empowerment treatment were asked to complete financial diaries to monitor daily expenditures in real time. Two hundred forty financial diaries were distributed to study participants during the financial literacy sessions at 8 sites. A total of 26,919 expense entries were recorded over 6 months. Sex work related expenses comprised approximately 20.01% of the total. The process of obtaining quality and consistent data was challenging due to the transient and stigmatized nature of sex work coupled with women's varying levels of education. Frequent check-ins, using peer support, code word or visuals, and a shorter timeframe would allow for a more accurate collection of high frequency data. Moreover, the ability of women to complete the financial diaries despite numerous challenges speaks to their potential value as a data collection tool, and also as an organizing tool for finances.
RESUMEN
Background: Women Engaged in commercial Sex Work (WESW) are exposed to behavioral, biological, and structural factors that exacerbate their risk to HIV infection and other sexually transmitted infections. While commercial sex work may appear voluntary, WESW are more likely to be constrained to selling sex due to limited viable alternatives. To effectively support this vulnerable group of women, it is critical to understand factors that facilitate and impede their decisions to transition from sex work into other careers or jobs. The current study explored women's decision to transition from sex work into other careers or jobs. Methods: Semi-structured in-depth interviews were conducted with 53 WESW aged 20-47 enrolled within a larger study-Kyaterekera study, a randomized clinical trial (N = 542) implemented in 19 HIV hotspots in the Southern region of Uganda. Participants were selected based on their intervention attendance (high/medium/low attendance). The interviews were conducted in Luganda the widely spoken language in the study area to explore the factors influencing women's decisions to from transition from sex work to other jobs or careers. The main interview question used for this study was, "What are some of the factors that may influence whether you would transition from sex work to other jobs or vocations?". All interviews were audio-recorded, transcribed verbatim and translated into English. Thematic analysis in Dedoose software was used to analyze the data. Results: Participants reported three primary types of decisions, including considering leaving sex work, deciding to leave, and continuing sex work. The emerging themes from the interviews were categorized into individual and structural level facilitators and barriers to leave sex work. Individual level factors included issues of stigma, discrimination, and aging as factors that facilitated women's decision to leave sex work. At the structural level, factors which include interpersonal stigma and discrimination (from immediate family and community members), physical and sexual violence and income related factors were identified as facilitators and barriers to leaving sex work. Conclusion: Our study highlights the complex decision-making processes among WESW as they navigate transitions to alternative jobs or careers. By advocating for multifaceted interventions and policies tailored to the diverse challenges faced by WESW, our study contributes to a more informed approach to supporting their transition out of sex work.
RESUMEN
Family functioning plays a critical role in childhood disruptive behavior disorders (The Family Journal, 2003, 11(1), 33-41; Research in Nursing and Health, 2016, 39(4), 229-243). Yet, there is limited research on the impact of evidence-based family strengthening interventions on improving family cohesion as a protective factor among children experiencing behavioral challenges. To address this gap, we analyzed data (N = 636) from the SMART Africa-Uganda study (2016-2022), a cluster randomized clinical trial testing an evidence-based family-strengthening intervention called Amaka Amasanyufu (translated as "Happy Families" in the local language). Children aged 8-13 and their caregivers were recruited from 26 public primary schools that were randomized to: (1) control condition receiving generalized psychosocial literature (10 schools), (2) intervention delivered via parent peers (eight schools), and (3) intervention delivered via community healthcare workers (eight schools). Children completed the family cohesion questionnaire at baseline, 8 weeks, 16 weeks, and 6 months post-intervention completion. The intervention effectiveness was evaluated via a three-level logistic mixed effects model with pairwise comparisons across study conditions within each time point. Participants in the parent-peer intervention group had greater odds of being in the higher family cohesion group than participants in the control group at 8 weeks (OR = 3.24), 16 weeks (OR = 1.88) and 6 months (OR = 2.07). At 8 weeks, 16 weeks, and 6 months, participants in the community health worker group had 3.98, 2.08, and 1.79 times greater odds of being in the higher family cohesion group than participants in the control group, respectively. Our findings strengthen the evidence base for Amaka Amansayufu as an effective intervention that can be utilized in SSA to improve family cohesion in families with children experiencing behavioral challenges.
RESUMEN
In Uganda, women engaged in sex work (WESW) are a marginalized population at the intersection of multiple vulnerabilities. The Kyaterekera intervention is targeted at WESW in Rakai and the greater Masaka regions in Uganda and combines a traditional HIV risk-reduction approach with a savings-led economic empowerment intervention and financial literacy training. We estimated the economic costs of the Kyaterekera intervention from a program provider perspective using a prospective activity-based micro-costing method. All program activities and resource uses were measured and valued across the control arm receiving a traditional HIV risk-reduction intervention and the treatment arm receiving a matched individual development savings account and financial literacy training on top of HIV risk reduction. The total per-participant cost by arm was adjusted for inflation and discounted at an annual rate of 3% and presented in 2019 US dollars. The total per-participant costs of the control and intervention arms were estimated at $323 and $1,435, respectively, using the per-protocol sample. When calculated based on the intent-to-treat sample, the per-participant costs were reduced to $183 and $588, respectively. The key cost drivers were the capital invested in individual development accounts and personnel and transportation costs for program operations, linked to WESW's higher mobility and the dispersed pattern of hot spot locations. The findings provide evidence of the economic costs of implementing a targeted intervention for this marginalized population in resource-constrained settings and shed light on the scale of potential investment needed to better achieve the health equity goal of HIV prevention strategies.
Asunto(s)
Infecciones por VIH , Asunción de Riesgos , Trabajadores Sexuales , Humanos , Uganda , Femenino , Infecciones por VIH/prevención & control , Infecciones por VIH/economía , Trabajadores Sexuales/psicología , Adulto , Conducta Sexual , Poblaciones Vulnerables , Conducta de Reducción del Riesgo , Estudios Prospectivos , Trabajo SexualRESUMEN
Women employed by sex work (WESW) experience significant gaps in accessing necessary healthcare services, leading to unmet health needs. Yet, there is a dearth of literature on the barriers to medical care access among WESW in Uganda. We used data from the Kyaterekera baseline to examine the correlates of access to medical care among WESW, defined as the ability of individuals to obtain the necessary healthcare services they require in a timely, affordable, and equitable manner. The Kyaterekera study recruited 542 WESW aged 18-58 years from Southern Uganda. We conducted a multilevel linear regression model to determine the intrapersonal (age, education level, marital status, HIV knowledge, and asset ownership), interpersonal (family cohesion and domestic violence attitudes), and community (community satisfaction, sex work stigma and distance to health facility) level correlates of access to medical care among WESW. Intrapersonal and interpersonal factors were associated with access to medical care among WESW. There was no significant association between community level factors and access to medical care. WESW with secondary education (ß = 0.928, 95% CI = 0.007, 1.849) were associated with increased access to medical care. WESW with high asset ownership (ß = -1.154, 95% CI= -1.903, -0.405), high family cohesion (ß = -0.069, 95% CI= -0.106, -0.031), and high domestic violence attitudes (ß = -0.253, 95% CI= -0.438, -0.068) were associated with decreased access to medical care. The findings emphasize the critical need for targeted family strengthening interventions to enhance family support for WESW and address domestic violence.
Asunto(s)
Infecciones por VIH , Accesibilidad a los Servicios de Salud , Trabajadores Sexuales , Estigma Social , Humanos , Femenino , Adulto , Estudios Transversales , Uganda , Persona de Mediana Edad , Adolescente , Trabajadores Sexuales/psicología , Trabajadores Sexuales/estadística & datos numéricos , Adulto Joven , Infecciones por VIH/psicología , Conocimientos, Actitudes y Práctica en Salud , Violencia Doméstica/psicología , Violencia Doméstica/estadística & datos numéricos , Factores Socioeconómicos , Aceptación de la Atención de Salud/psicología , Aceptación de la Atención de Salud/estadística & datos numéricosRESUMEN
BACKGROUND: Children and adolescents who live in resource-limited communities in sub-Saharan Africa (SSA) experience significant mental health problems, including behavioral problems. In SSA, one of the most significant impediments to expanding services is a scarcity of mental health specialists. Task-shifting can effectively solve the mental health care gap in low-resource settings, yet it is underutilized in child and adolescent mental health. Moreover, the experiences of lay providers are understudied in global mental health, despite their potential impact on intervention effectiveness. In this study, we examined the experiences of community health workers and parent peers with the task-shifting of an evidence-based family strengthening intervention in Uganda. METHODS: As part of a larger randomized clinical trial, semi-structured in-depth interviews were conducted with 24 facilitators selected using stratified purposive sampling. Interviews explored their decision to participate in the program; experiences with the training; and experiences with intervention delivery. All interviews were conducted in Luganda (local language) and audio recorded. They were transcribed verbatim and translated into English. Thematic analysis was used to analyze the data. RESULTS: Despite concerns around lack of previous experience and time commitment, facilitators reported high relevance of the intervention to the families in their communities as well as their own as a motivation to participate. They also identified financial incentives as a motivating factor. These two factors also ensured their attendance at the training. They were satisfied with the content and skills provided during the training and felt prepared to deliver the intervention. During intervention delivery, they enjoyed seeing the families engaged and participating actively in the sessions as well as observing positive changes in the families. Some challenges with family attendance and engagement were noted. The facilitators reported an increased sense of self-efficacy and competence over time; and expressed high satisfaction with supervision. CONCLUSION: Facilitators' positive experiences point to the high acceptability and appropriateness of task-shifting this intervention in low-resource settings. As the global mental health field continues to be interested in task-shifting interventions to lay providers, successful examples should be studied so that evidence-based models can be put in place to support them through the process.
RESUMEN
Sexual risky behaviors among adolescents and young people remain a major public health problem worldwide. This study examined the impact of parent-adolescent communication on adolescents' possibility to engage in risky behaviors. The study used baseline data from the Suubi-Maka Study (2008-2012) implemented in 10 primary schools in Southern Uganda. Binary logistic regression models were conducted to determine the association between parent-adolescent communication and sexual risk possibility. Results indicate that gender [OR 0.220, 95% CI 0.107, 0.455], age [OR 1.891, 95% CI 1.030, 3.471], household size [OR 0.661, 95% CI 0.479, 0.913], and comfort level of family communication [OR 0.944, 95% CI 0.899, 0.990] were significantly associated with lower levels of sexual risk possibility among adolescents. There is a need to build interventions that make it easy and comfortable for adolescents to have open discussion and communication with parents on sexual risk possibility, risky behaviors, and risky situations.
Asunto(s)
Conducta del Adolescente , Humanos , Adolescente , Padres , Conducta Sexual , Modelos Logísticos , Comunicación , Relaciones Padres-HijoRESUMEN
Intimate partner violence (IPV) is a significant global public health problem that results in high social and economic costs to individuals and communities. Compared to women in the general population, women engaged in sex work (WESW) are more likely to experience physical, emotional, and sexual IPV. This study examines the correlates of IPV among young WESW with their intimate partners in Southern Uganda. We used baseline data from the Kyaterekera project, a 5 year NIH-funded longitudinal study aimed at reducing HIV risks among 542 WESW in Southern Uganda. To examine the factors associated with IPV, we fitted three separate multi-level Poisson regression models for physical, emotional, and sexual IPV, respectively. Average age was 31.4 years, and 54% of the women reported being victims of at least one form of IPV from their intimate partners. Model one assessed correlates of sexual IPV. Being married women (ß = .71, 95% CI [0.24, 1.17]), divorced/separated/widowed (ß = .52, [0.02, 1.02]), depressed (ß = .04, [0.02, 0.05]), and having any sexually transmitted infections (STIs) (ß = .58, [0.14, 1.01]) were associated with sexual IPV. Model two assessed correlates of physical IPV. Experience of childhood sexual abuse (ß = .12, [0.04, 0.19]) was associated with an increase in physical IPV, and increasing age reduced its occurrence (ß = -.02, [-0.04, -0.001]). Finally, model three assessed emotional IPV. Women with higher education (ß = .49, [0.14, 0.85]) and symptoms of depression (ß = .02, [0.001, 0.04]) had higher risks for emotional IPV. For WESW, IPV presents an additional potential pathway for HIV and STIs acquisition and transmission through a lack of negotiating power for safe sex. Efforts to reduce violence against WESW should be prioritized as a strategy for enhancing the well-being of WESW.
Asunto(s)
Infecciones por VIH , Violencia de Pareja , Enfermedades de Transmisión Sexual , Humanos , Femenino , Adulto , Infecciones por VIH/epidemiología , Factores de Riesgo , Trabajo Sexual , Uganda/epidemiología , Estudios Longitudinales , Violencia de Pareja/psicología , Enfermedades de Transmisión Sexual/epidemiología , Parejas Sexuales/psicología , PrevalenciaRESUMEN
BACKGROUND: Women employed by sex work (WESW) have a high risk of human immunodeficiency virus (HIV) infection and experience economic barriers in accessing care. However, few studies have described their financial lives and the relationship between expenditures and HIV-related behaviors. METHODS: This exploratory study used financial diaries to collect expenditure and income data from WESW in Uganda over 6 months. Data were collected as part of a larger trial that tested the efficacy of an HIV prevention intervention method. Descriptive statistics were used to quantify women's income, relative expenditures, and negative cash balances. Bivariate and multivariate logistic regressions were used to examine the odds of sexual risk behavior or use of HIV medications for several cash scenarios. RESULTS: A total of 163 WESW were enrolled; the participants mean age was 32 years old. Sex work was the sole source of employment for most WESW (99%); their average monthly income was $62.32. Food accounted for the highest proportion of spending (44%) followed by sex work (20%) and housing expenditures (11%). WESW spent the least on health care (5%). Expenditures accounted for a large but variable proportion of these women's income (56% to 101%). Most WESW (74%) experienced a negative cash balance. Some also reported high sex work (28%), health care (24%), and education (28%) costs. The prevalence of condomless sex (77%) and sex with drugs/alcohol (70%) was high compared to use of ART/PrEP (Antiretroviral therapy/Pre-exposure prophylaxis) medications (45%). Women's cash expenditures were not statistically significantly associated with HIV-related behaviors. However, the exploratory study observed a consistent null trend of lower odds of condomless sex (adjusted odds ratio (AOR) = 0.70, 95% confidence interval (CI): 0.28-1.70), sex with drugs/alcohol (AOR = 0.93, 95% CI: 0.42-2.05), and use of ART/PrEP (AOR = 0.80, 95% CI: 0.39-1.67) among women who experienced a negative cash balance versus those who did not. Similar trends were observed for other cash scenarios. CONCLUSION: Financial diaries are a feasible tool to assess the economic lives of vulnerable women. Despite having paid work, most WESW encountered a myriad of financial challenges with limited spending on HIV prevention. Financial protections and additional income-generating activities may improve their status. More robust research is needed to understand the potentially complex relationship between income, expenditures, and HIV risk among vulnerable sex workers.
Asunto(s)
Infecciones por VIH , Trabajo Sexual , Humanos , Femenino , Adulto , Gastos en Salud , Uganda/epidemiología , Conducta Sexual , Infecciones por VIH/prevención & controlRESUMEN
PURPOSE: Depression is among the leading causes of disability and contributes significantly to the overall disease burden affecting children. Family cohesion has been identified as a protective factor against depression. Examining this relationship is necessary in sub-Saharan Africa, specifically in Uganda-a country characterized by a high prevalence of HIV/AIDS, and high rates of chronic poverty, all of which stress family functioning and elevate child behavioral challenges. This study examined the relationship between family cohesion and depression among school-going children with elevated symptoms of behavioral challenges in southern Uganda. METHODS: At baseline, 2089 children were enrolled in the National Institutes of Health-funded Strengthening Mental Health and Research Training Africa study in Southwestern Uganda. This article analyzed data from 626 children aged 8-13 years with elevated behavioral challenges. We conducted multilevel mixed-effects Poisson regression to determine the association between family cohesion and depression. We controlled for sociodemographic and household characteristics. RESULTS: The mean age was 10.3 years. The overall mean depression score was 3.2 (standard deviation = 2.7, range = 0-15). Family cohesion (ß = -0.03, 95% confidence interval [CI]: -0.04, -0.02, p < .001) and owning essential items by the child (ß = -0.13, 95% CI: -0.23, -0.04, p = .005) were protective against depression among children. Additionally, we observed being a single orphan (ß = -0.44, 95% CI: -0.03, -0.86, p = .036) and having both parents (ß = -0.43, 95% CI: -0.06, -0.81, p = .023) were associated with depression among children. DISCUSSION: Findings from this study reveal that family cohesion was protective against depression. Therefore, it is vital to strengthen family support systems by developing programs aimed at strengthening family relationships as a catalyst for addressing depression among children.
Asunto(s)
Síndrome de Inmunodeficiencia Adquirida , Depresión , Humanos , Niño , Depresión/epidemiología , Uganda/epidemiología , Relaciones Familiares/psicología , Instituciones AcadémicasRESUMEN
PURPOSE: Disruptive behavioral disorders (DBDs) are common among children/adolescents in sub-Saharan Africa. A 16-week manualized multiple family group (MFG) intervention called Amaka Amasanyufu designed to reduce DBDs among school-going children/adolescents in low-resource communities in Uganda was efficacious in reducing symptoms of poor mental health relative to usual care in the short-term (4 months post-intervention-initiation). We examined whether intervention effects are sustained 6 months postintervention. METHODS: We used longitudinal data from 636 children positive for DBDs: (1) Control condition, 10 schools, n = 243; (2) MFG delivered via parent peers (MFG-PP), eight schools, n = 194 and; (3) MFG delivered via community healthcare workers (MFG-CHW), eight schools, n = 199 from the SMART Africa-Uganda study (2016-2022). All participants were blinded. We estimated three-level linear mixed-effects models and pairwise comparisons at 6 months postintervention and time-within-group effects to evaluate the impact on Oppositional Defiant Disorder (ODD), impaired functioning, depressive symptoms, and self-concept. RESULTS: At 6 months postintervention, children in MFG-PP and MFG-CHW groups had significantly lower means for ODD (mean difference [MD] = -1.08 and -1.35) impaired functioning (MD = -1.19 and -1.16), and depressive symptoms (MD = -1.06 and -0.83), than controls and higher means for self-concept (MD = 3.81 and 5.14). Most outcomes improved at 6 months compared to baseline. There were no differences between the two intervention groups. DISCUSSION: The Amaka Amasanyufu intervention had sustained effects in reducing ODD, impaired functioning, and depressive symptoms and improving self-concept relative to usual care at 6 months postintervention. Our findings strengthen the evidence that the intervention effectively reduces DBDs and impaired functioning among young people in resource-limited settings and was sustained over time.
Asunto(s)
Trastornos de la Conducta Infantil , Salud Mental , Humanos , Niño , Adolescente , Uganda , Conducta InfantilRESUMEN
PURPOSE: Antiretroviral therapy (ART) adherence among adolescents living with HIV (ALWHIV) is low, with poverty remaining a significant contributor. We examined the mediation pathways between an economic empowerment intervention and ART adherence among ALWHIV. METHODS: This cluster-randomized controlled trial (2012-2018) recruited 702 ALWHIV aged 10-16 in Uganda between January 2014 and December 2015. We randomized 39 clinics into the control (n = 344) or intervention group (n = 358). The intervention comprised a child development account, four microenterprise workshops, and 12 mentorship sessions. We used six self-reported items to measure adherence at 24 months, 36 months, and 48 months. We used structural equation modeling to assess the mediation effects through mental health and adherence self-efficacy, on adherence. We ran models corresponding to the 24, 36, and 48 months of follow-up. RESULTS: The mean age of the participants was 12 years, and 56% were female. At 36 (model 2) and 48 months (model 3), the intervention had a significant indirect effect on ART adherence [B = 0.069, ß = 0.039 (95% confidence interval [CI]: 0.005-0.074)], and [B = 0.068, ß = 0.040 (95% CI: 0.010-0.116)], respectively. In both models, there was a specific mediation effect through mental health [B = 0.070, ß = 0.040 (95% CI: 0.007-0.063)], and [B = 0.039, ß = 0.040 (95% CI: 0.020-0.117)]. Overall, 49.1%, 90.7%, and 36.8% of the total effects were mediated in models, 1, 2, and 3, respectively. DISCUSSION: EE interventions improve adherence, by improving mental health functioning. These findings warrant the need to incorporate components that address mental health challenges in programs targeting poverty to improve ART adherence in low-income settings.
Asunto(s)
Infecciones por VIH , Niño , Humanos , Adolescente , Femenino , Masculino , Uganda , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/psicología , Pobreza/psicología , Cumplimiento de la Medicación/psicología , Salud MentalRESUMEN
BACKGROUND: Women engaged in commercial sex work (WESW) are at a higher risk of acquiring and transmitting HIV. WESW are highly mobile, and their mobility may increase their economic status, and increased access to healthcare and other social services. However, it may also facilitate the spread of HIV infection from higher to lower prevalence regions. This study examined the predictors of mobility among WESW in Uganda using a generalized estimating equations model. METHODS: We defined and measured mobility as the change in residence by WESW between baseline, 6 months, and 12 months follow-up. Participants who changed places were considered mobile, and those who never changed were non-mobile. We used data from a longitudinal study, which recruited 542 WESW from Southern Uganda aged 18-55 years and constructed a Generalized Estimating Equations Model. RESULTS: Findings show that 19.6% of WESW changed residence between baseline and 6 months of follow-up and 26.2% (cumulative) between baseline and 12 months of follow-up. Older women (OR = 0.966, 95% CI = 0.935, 0.997) were associated with decreased odds of mobility, whereas WESW who were HIV positive (OR = 1.475, 95% CI = 1.078, 2.018) and those from large households (OR = 1.066, 95% CI = 1.001, 1.134) were associated with increased odds of mobility. WESW residing in rural areas (OR = 0.535, 95% CI = 0.351, 0.817) were associated with decreased odds of mobility compared to those from fishing sites. CONCLUSION: The results indicate risk factors for mobility, further research is needed to determine the directionality of these factors in order to design interventions addressing mobility among WESW.
Asunto(s)
Infecciones por VIH , Trabajo Sexual , Humanos , Femenino , Anciano , Infecciones por VIH/epidemiología , Conducta Sexual , Estudios Longitudinales , Uganda/epidemiologíaRESUMEN
PURPOSE: We explored the factors influencing sexual risk-taking attitudes-defined as beliefs and values regarding sexual activity-among adolescents living with human immunodeficiency virus (ALHIV) in Uganda. METHODS: The study used baseline data from a five-year cluster-randomized control trial (2012-2018) among 702 ALHIV in Uganda. Participants were aged 10-16 years, HIV-positive, taking antiretroviral therapy, and living within a family. We fitted hierarchical regression models to assess the demographic, economic, psychological, and social predictors of sexual risk-taking attitudes. Using R2, the final model explained 11.4% of the total variance. RESULTS: Under economic factors, caregiver being formally employed (ß = -0.08, 95% confidence interval [CI]: -0.10-0.06, p < .001), and the ALHIV working for pay (ß = 1.78, 95% CI: 0.28-3.29, p = .022), were associated with sexual risk-taking attitudes. Among the psychological factors, more depressive symptoms (ß = 0.22, 95% CI: 0.11-0.32, p < .001) were associated with more approving attitudes toward sexual risk-taking. Family and social factors including communicating with the caregiver about HIV (ß = 1.32, 95% CI: 0.56-2.08, p = .001), sex (ß = 1.09, 95% CI: 0.20-1.97, p = .017), and experiencing peer pressure (ß = 3.37, 95% CI: 1.85-4.89, p < .001) were also associated with more approving attitudes toward sexual risk-taking. The final model explained 11.54% of the total variance. DISCUSSION: Economic, psychological, and social factors influence sexual risk-taking attitudes among ALHIV. There is a need for more research to understand why discussing sex with caregivers improves adolescents' positive attitudes toward sexual risk-taking. These findings have significant ramifications in preventing sexual transmission of HIV among adolescents in low-income settings.
Asunto(s)
Infecciones por VIH , VIH , Humanos , Adolescente , Uganda , Infecciones por VIH/prevención & control , Actitud , Conducta Sexual/psicología , Asunción de RiesgosRESUMEN
BACKGROUND: The HIV burden remains a critical public health concern and women engaged in sex work [WESW] are at significantly higher risk compared to the general adult population. Similar to other sub-Saharan African countries, Uganda reports high rates of HIV prevalence among WESW. Yet, they have not been targeted by theory-informed HIV prevention intervention approaches. METHODS: We conducted semi-structured in-depth interviews with 20 WESW upon intervention completion to explore their experiences with an evidence-based HIV risk reduction intervention that was implemented as part of a combination intervention tested in a clinical trial in Uganda (2018-2023. Specifically, we explored their initial motivations and concerns for participating in the intervention, barriers and facilitators to attendance, and their feedback on specific intervention characteristics. RESULTS: The main expectations revolved around access to health-related information, including information on STIs, HIV, and PrEP as well as on how one can protect themselves while engaging in sex work. Initial concerns were around potential breach of confidentiality and fear of arrest. The main facilitators for session attendance were the motivation to learn health-related information, the attitude of facilitators, and the incentives received for participation, whereas main challenges were related to family commitments and work schedules. WESW appreciated the group format of the intervention and found the location and times of the intervention delivery acceptable. DISCUSSION AND CONCLUSIONS: Overall, our findings suggest that the HIV risk reduction intervention was appropriate and acceptable to WESW. Yet, WESW experience unique concerns and barriers that need to be accounted for when designing interventions targeting this population, especially in resource-limited settings where sex work is illegal and highly stigmatized. CLINICAL TRIAL REGISTRATION: NCT03583541.
Asunto(s)
Infecciones por VIH , Trabajo Sexual , Adulto , Femenino , Humanos , Infecciones por VIH/epidemiología , Infecciones por VIH/prevención & control , Infecciones por VIH/tratamiento farmacológico , Investigación Cualitativa , Conducta de Reducción del Riesgo , Uganda/epidemiologíaRESUMEN
Economic hardship is a driver of entry into sex work, which is associated with high HIV risk. Yet, little is known about economic abuse in women employed by sex work (WESW) and its relationship to uptake of HIV prevention and financial support services. This study used cross-sectional baseline data from a multisite, longitudinal clinical trial that tests the efficacy of adding economic empowerment to traditional HIV risk reduction education on HIV incidence in 542 WESW. Mixed effects logistic and linear regressions were used to examine associations in reported economic abuse by demographic characteristics, sexual behaviors, HIV care-seeking, and financial care-seeking. Mean age was 31.4 years. Most WESW were unmarried (74%) and had less than primary school education (64%). 48% had savings, and 72% had debt. 93% reported at least one economic abuse incident. Common incidents included being forced to ask for money (80%), having financial information kept from them (61%), and being forced to disclose how money was spent (56%). WESW also reported partners/relatives spending money needed for bills (45%), not paying bills (38%), threatening them to quit their job(s) (38%), and using physical violence when earning income (24%). Married/partnered WESW (OR = 2.68, 95% CI:1.60-4.48), those with debt (OR = 1.70, 95% CI:1.04-2.77), and those with sex-work bosses (OR = 1.90, 95% CI:1.07-3.38) had higher economic abuse. Condomless sex (ß = +4.43, p < .05) was higher among WESW experiencing economic abuse, who also had lower odds of initiating PrEP (OR = .39, 95% CI:.17-.89). WESW experiencing economic abuse were also more likely to ask for cash among relatives (OR = 2.36, 95% CI:1.13-4.94) or banks (OR = 2.12, 95% CI:1.11-4.03). The high prevalence of HIV and economic abuse in WESW underscores the importance of integrating financial empowerment in HIV risk reduction interventions for WESW, including education about economic abuse and strategies to address it. Programs focusing on violence against women should also consider economic barriers to accessing HIV prevention services.
Asunto(s)
Infecciones por VIH , Trabajo Sexual , Femenino , Humanos , Adulto , Estudios Transversales , Uganda , Infecciones por VIH/prevención & control , Infecciones por VIH/epidemiología , Apoyo FinancieroRESUMEN
We examined the impact of a family-based economic strengthening intervention on school dropout and repeating a class among ALWHIV in Uganda. In this cluster-randomized trial (2012-2018) conducted in 39 clinics, we recruited adolescents aged 10-16 years living with HIV. We included data from 613 adolescents. We plotted a Kaplan Meier survival curve and fitted Cox proportional hazards models to test the effect of the economic strengthening intervention on school dropout. The incidence of school dropout was 13.0% and 9.6% in the control and intervention groups, respectively. Also, economic empowerment reduced the risk of school dropout, aHR = 0.68 (95% CI 0.52-0.88), p-value 0.004. In other words, participants in the intervention group had 32% reduced hazards of dropping out of school. Also, increasing age aHR = 1.54 (95% CI 1.42-1.66), p-value < 0.001 and double orphanhood aHR = 0.67 (95% CI 0.47-0.96) p-value 0.030 increased the risks for dropping out of school. The intervention was not efficacious in reducing the rates of repeating a class. The intervention offered the ALWHIV an opportunity to live a productive adult life. More research is required on these kinds of interventions intended to keep ALWHIV and those impacted by HIV in school.
Asunto(s)
Éxito Académico , Infecciones por VIH , Adulto , Humanos , Adolescente , Uganda , Escolaridad , Instituciones AcadémicasRESUMEN
We examined the correlates of self-reported adherence to antiretroviral therapy (ART) among women engaged in commercial sex work (WESW) in Uganda. We used baseline data from a longitudinal study, which recruited 542 WESW in Southern Uganda. We used nested regression models to determine the individual and family, and economic level correlates of self-reported adherence. Study findings show that older age (OR = 1.07, 95% CI = 1.013, 1.139), secondary education (OR = 2.01, 95% CI = 1.306, 3.084), large household size (OR = 1.08, 95% CI = 1.020, 1.136), high family cohesion (OR = 1.06, 95% CI = 1.052, 1.065), and high financial self-efficacy (OR = 1.07, 95% CI = 1.006, 1.130) were associated with good self-reported adherence to ART. Married women (OR=-0.39, 95% CI = 0.197, 0.774), depression (OR = 0.85, 95% CI = 0.744, 0.969), alcohol use (OR = 0.72, 95% CI = 0.548, 0.954), ever been arrested (OR = 0.58, 95% CI = 0.341, 0.997), and high household assets ownership (OR = 0.48, 95% CI = 0.313, 0.724) were associated with poor self-reported adherence to ART. Findings suggest a need to adopt a multi-level approach to address gaps in ART adherence among WESW.
Asunto(s)
Infecciones por VIH , Trabajo Sexual , Humanos , Femenino , Autoinforme , Uganda , Estudios Longitudinales , Cumplimiento de la MedicaciónRESUMEN
We examined the factors associated with consistent condom use among women engaged in sex work in the Southern parts of Uganda. We used baseline data from a longitudinal study involving WESW from 19 hotspots in Southern Uganda. We conducted hierarchical models to determine the individual, economic, behavioral, and health-related factors associated with consistent condom use. We found that, alcohol use (b=-0.48, 95% CI=-0.77, -0.19), accepting money for condomless sex (b=-0.33, 95% CI=-0.38, -0.28), multiple customers (b=-0.01, 95% CI=-0.01, -0.005), being married (b = 0.50, 95% CI = 0.01, 0.99), owning more assets (b = 0.08, 95% CI = 0.05, 0.13), having another income earner in the household (b = 0.55, 95% CI = 0.27, 0.83), condom use self-efficacy (b = 0.11, 95% CI = 0.03, 0.19), condom use communication (b = 0.06, 95% CI = 0.001, 0.12), and being knowledgeable about HIV/STIs transmission (b = 0.08, 95% CI = 0.01, 0.15) were associated with consistent condom use. Additionally, 29% of the women were consistent condom users. Hence, there is need to implement interventions that promote consistent condom use among WESW.