The proposed study will examine the efficacy of a combined HIV and microfinance intervention to reduce biologically confirmed sexually transmitted infections (STIs), and new incidence of HIV and HCV, as well as reported sexual and drug risk behaviors among 520 women who have injected drugs in the past year and who engage in sex trading in Temirtau and Pavlodar, Kazakhstan. Kazakhstan is one of nine countries worldwide that has experienced a continuing rise in HIV infections (>25%) over the past decade. The epidemic is exacerbated by structural forces such as poverty and a lack of employment options for people who use drugs, especially women, which makes transactional sex a survival strategy. Recent calls for action by HIV prevention scientists have emphasized the need for innovative structural interventions for women engaged in sex work who are also drug-involved. The proposed study builds on findings from an R34 by the investigative team testing a combination HIV prevention and microfinance intervention. Building on successful protocols and significant results, we will randomly assign 520 women who inject drugs and engage in sex trading from Temirtau and Pavlodar, Kazakhstan to either (1) a 4 session HIV prevention intervention combined with a 6 session financial literacy intervention, enrollment in an existing vocational training program and receipt of matched savings (HIVRR+MF);or to the 4 session HIV prevention intervention alone. The HIVRR intervention is guided by social cognitive theory. The HIVRR+MF intervention integrates asset theory with social cognitive theory. The MF includes: 1) financial literacy;2) vocational training;and 3) micro-savings to support transitionto a more permanent employment status. We hypothesize that increasing financial literacy, enhancing vocational skills required to fill marketable positions in the local economy, and beginning a personal savings program, combined with HIV risk reduction, will lead to significant reductions in study outcomes compared to an HIVRR intervention without a microfinance intervention. A qualitative component to examine factors that facilitate or impede women's ability to participate in and benefit from a microfinance intervention, and a cost and cost effectiveness analysis will provide additional data to inform a disseminable program if findings are significant. The findings from this study will be important not only for Central Asia, but may also have vital public health implications in the U.S. and other countries where HIV/STIs and HCV remain high and employment rates remain low among drug- involved women engaged in sex trading.
This study responds to the identified need in HIV research for rigorous testing of structural interventions, including combination microfinance and HIV prevention among women at high risk for HIV/STI and HCV, where gender and economic issues restrict the impact of existing individually-based prevention strategies. The findings from this study will have important HIV prevention and public health implications for Central Asia and other countries where HIV prevalence rates remain high and the legal employment rates are limited among drug- involved women engaged in sex trading. Lessons learned from this study can guide similar research in the U.S. among this group of vulnerable women.