Personal and Financial Risk Typologies Among Women Who Engage in Sex Work in Mongolia: A Latent Class Analysis.

Women engaged in sex work bear a disproportionate burden of HIV infection worldwide, particularly in low- to middle-income countries. Stakeholders interested in promoting prevention and treatment programs are challenged to efficiently and effectively target heterogeneous groups of women. This problem is particularly difficult because it is nearly impossible to know how those groups are composed a priori. Although grouping based on individual variables (e.g., age or place of solicitation) can describe a sample of women engaged in sex work, selecting these variables requires a strong intuitive understanding of the population. Furthermore, this approach is difficult to quantify and has the potential to reinforce preconceived notions, rather than generate new information. We aimed to investigate groupings of women engaged in sex work. The data were collected from a sample of 204 women who were referred to an HIV prevention intervention in Ulaanbaatar, Mongolia. Latent class analysis was used to create subgroups of women engaged in sex work, based on personal and financial risk factors. This analysis found three latent classes, representing unique response pattern profiles of personal and financial risk. The current study approached typology research in a novel, more empirical way and provided a description of different subgroups, which may respond differently to HIV risk interventions.

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 (ß = -0.867, p < 0.001), physical violence (ß = -0.0923, p < 0.001), and sexual violence (ß = -1.639, p = 0.001) from paying partners. No significant differences between groups were found for any violence (ß = 0.118, p = 0.389), physical violence (ß = 0.091, p = 0.792), or sexual violence (ß = 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.

Efficacy of a savings-led microfinance intervention to reduce sexual risk for HIV among women engaged in sex work: a randomized clinical trial.

OBJECTIVES: We tested whether a structural intervention combining savings-led microfinance and HIV prevention components would achieve enhanced reductions in sexual risk among women engaging in street-based sex work in Ulaanbaatar, Mongolia, compared with an HIV prevention intervention alone. METHODS: Between November 2011 and August 2012, we randomized 107 eligible women who completed baseline assessments to either a 4-session HIV sexual risk reduction intervention (HIVSRR) alone (n=50) or a 34-session HIVSRR plus a savings-led microfinance intervention (n=57). At 3- and 6-month follow-up assessments, participants reported unprotected acts of vaginal intercourse with paying partners and number of paying partners with whom they engaged in sexual intercourse in the previous 90 days. Using Poisson and zero-inflated Poisson model regressions, we examined the effects of assignment to treatment versus control condition on outcomes. RESULTS: At 6-month follow-up, the HIVSRR plus microfinance participants reported significantly fewer paying sexual partners and were more likely to report zero unprotected vaginal sex acts with paying sexual partners. CONCLUSIONS: Findings advance the HIV prevention repertoire for women, demonstrating that risk reduction may be achieved through a structural intervention that relies on asset building, including savings, and alternatives to income from sex work.

Reducing risk behaviors linked to noncommunicable diseases in Mongolia: a randomized controlled trial.

OBJECTIVES: We tested the efficacy of a 6-session, evidence-based health promotion intervention aimed at reducing noncommunicable disease (NCD) risk behaviors. METHODS: Two hundred male and female factory workers in Ulaanbaatar, Mongolia were randomly assigned to groups receiving either the health promotion intervention or a time-matched financial literacy control intervention. RESULTS: The health promotion intervention increased daily fruit and vegetable intake and physical activity, increased readiness for NCD risk behavior reduction and health promotion knowledge, and reduced the number of daily alcoholic drinks and diabetes symptoms 3 months after the intervention. CONCLUSIONS: The findings support the efficacy of the intervention to reduce risk behaviors associated with NCDs. Dissemination of the intervention may improve productivity, reduce costs of health services, and better the quality of life for Mongolians.

Reducing sexual HIV/STI risk and harmful alcohol use among female sex workers in Mongolia: a randomized clinical trial.

This study examined the efficacy of an enhanced intervention to reduce sexual risk of HIV/STI and harmful alcohol use among female sex workers in Mongolia. Women (n = 166) were recruited and randomized to either (1) a relationship-based HIV sexual risk reduction intervention; (2) the same sexual risk reduction intervention plus motivational interviewing; or (3) a control condition focused on wellness promotion. At three and six month follow-up, both treatment interventions and the wellness promotion condition were effective in reducing the percentage and the number of unprotected acts of vaginal sex with paying partners in the past 90 days. All three conditions demonstrated efficacy in reducing harmful alcohol use. No significant differences in effects were observed between conditions. Findings suggest that even low impact behavioral interventions can achieve considerable reductions of HIV/STI risk and harmful alcohol use with a highly vulnerable population in a low resourced setting.

The impact of violence, perceived stigma, and other work-related stressors on depressive symptoms among women engaged in sex work.

While the physical health risks of sex work have been well documented, fewer studies have explored mental health risks associated with sex work. This study examined rates of depressive symptoms and associated risk factors among women engaged in sex work in Mongolia (n=222), a country experiencing significant economic and social development and where mental health infrastructure is in its infancy. A linear regression analysis indicated that significant risk factors for depressive symptoms included paying partner sexual violence, perceived occupational stigma, less social support, and higher harmful alcohol use. As one of the first studies to examine depression among sex workers, this study holds important social welfare implications for this marginalized population in Mongolia and other low-resource settings globally.

"There is no other option; we have to feed our families who else would do it?": The financial lives of women engaging in sex work in Ulaanbaatar, Mongolia.

INTRODUCTION: This article provides an overview of the financial lives of women (n = 204) engaging in sex work in Ulaanbaatar, Mongolia. METHODS: This paper presents findings from a computer-based, interviewer-administered baseline assessment administered with women recruited for participation in a randomized controlled trial testing the feasibility of a combined HIV risk reduction and savings-led microfinance intervention for women engaging in sex work in Mongolia. FINDINGS: Findings demonstrate that most women are the primary financial providers for their households, using an array of earning strategies to provide for themselves and other dependents, with sex work often constituting the primary household income source. Financial instability in the lives of people engaging in sex work may increase their risk for HIV and STIs due to a compromised ability to negotiate safer sex with partners in times of economic crisis or need. High levels of financial responsibility for household welfare, when combined with low reported savings, the presence of debt, higher premiums offered for sex without a condom, and high levels of harmful alcohol use, may heighten women's risk for HIV and other STIs. CONCLUSION: Further research that documents the financial lives of people working in sex work is needed in order to understand the complex relationship between financial stability and engagement in sex work, and to inform the development and testing of structural HIV prevention interventions which target the economic determinants of risk. These findings highlight the importance of economic support programming for women engaged in sex work in Mongolia at a time of rapid economic change in Mongolia.

Piloting a Savings-Led Microfinance Intervention with Women Engaging in Sex Work in Mongolia: Further Innovation for HIV Risk Reduction.

This paper describes a pilot study testing the feasibility of an innovative savings-led microfinance intervention in increasing the economic empowerment and reducing the sexual risk behavior of women engaging in sex work in Mongolia. Women's economic vulnerability may increase their risk for HIV by compromising their ability to negotiate safer sex with partners and heightening the likelihood they will exchange sex for survival. Microfinance has been considered a potentially powerful structural HIV prevention strategy with women conducting sex work, as diversification of income sources may increase women's capacity to negotiate safer transactional sex. With 50% of all reported female HIV cases in Mongolia detected among women engaging in sex work, direct prevention intervention with women conducting sex work represents an opportunity to prevent a potentially rapid increase in HIV infection in urban Mongolia. The piloted intervention consisted of a matched savings program in which matched savings could be used for business development or vocational education, combined with financial literacy and business development training for women engaging in sex work. Results of the pilot demonstrate participants' increased confidence in their ability to manage finances, greater hope for pursuing vocational goals, moderate knowledge gains regarding financial literacy, and an initial transition from sex work to alternative income generation for five out of nine participants. The pilot findings highlight the potential for such an intervention and the need for a clinical trial testing the efficacy of savings-led microfinance programs in reducing HIV risk for women engaging in sex work in Mongolia.