Acknowledgement

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

2. Acknowledgement • We wish to thank all of the women and men who courageously gave of their time and life experience to inform project goals • Mongolia Team: LkhamsurenBilguun, Erdentuya Lkhagvasuren, BolortungalagBatsaikhan, AltantsetsegGombo, Toivgoo Aira, AltantsetsegBatsukh, and many other faculty, students and community participants • Columbia/NY Team: Marion Riedel, Laura Cordisco Tsai, Susan Witte, Reid Offringa, Nabila El-Bassel, Fred Ssewamala • This study was made possible by a grant from the National Institute of Mental Health, R34MH093227 to PI Susan Witte.

3. Presentation will cover… • Women’s Wellness Pilot: Pilot to inform combination HIV prevention and alcohol use risk reduction intervention for women engaged in sex work (PI: Batsukh & Witte, 2005-2006) • Women’s Wellness Trial: Testing a combination HIV prevention and harmful alcohol use risk reduction intervention for women engaged in sex work (PI: Witte, 2008 – 2010) • Undarga Pilot: Lessons learned from a pilot to inform combination HIV prevention and microfinance intervention for women engaged in sex work (PI: Witte & Aira, 2010) • Undarga Trial: Feasibility trial of combination HIV prevention and savings-led microfinance intervention for women engaged in sex work (PI: Witte, 2010-2013)

5. HIV/STI and alcohol use in Mongolia • HIV prevalence low; however, • STIs high in general population • Poverty increasing • Worker transience increasing • Disproportionate unemployment and opportunity among women • Increased survival sex work among women caring for dependent children and parents • Increasing alcohol use (corresponding lack of treatment) • High stigma related to sex work, alcohol abuse among women • Host of other public health and social work issues related to access to services, training of professionals to provide service, and institutions to provide infrastructure for service delivery

6. Women’s Wellness Pilot, 2006 • Focus groups and self-administered surveys among 48 sex workers • Themes focused on sex work, sexual risk, intimate partner violence, alcohol abuse, psychological distress • 85% of women reported drinking at harmful levels (>8 on AUDIT); • 70% reported using condoms inconsistently with any partner; • 83% reported using alcohol before engaging in sex with paying partners, and • 38% reported high levels of depression • Determined ways that poverty, alcohol abuse, interpersonal violence, and cultural norms that stigmatize and marginalize women are intertwined risk factors for STIs, including HIV. Witte, S. S., Batsukh, A., & Chang, M. (2010). Sexual risk behaviors, alcohol abuse and intimate partner violence among sex workers in Mongolia: Implications for HIV prevention intervention development. Journal of Prevention and Intervention in the Community, 38, 89-103. PMCID: PMC2856489

7. Women’s Wellness Trial (2007-2010) • Study significance (Phase 1a/1b developmental clinical trial): • Inform development of a larger efficacy trial to more rigorously test the interventions in a clinical trial with a larger sample of women • Advance science of HIV prevention and alcohol treatment among vulnerable women in Mongolia; • Build research capacity within Mongolia for HIV/STI and alcohol-related issues • Funded by the National Institute on Alcohol and Alcohol Abuse, NIAAA (U.S.)

8. Primary Aims Aim 1: To adapt and combine two interventions: a 4 group session manualized HIV sexual risk reduction intervention (HIV-SRR) developed, tested and adapted by CU team investigators; and a 2-session manualized motivational interviewing (MI) intervention, and tailor them to alcohol-abusing women engaging in sexual risk behaviors in Mongolia; Aim 2: To conduct a 3-arm randomized clinical trial (RCT) with 165 women engaged in sex work, assigned to either the combination (HIV-SRR+MI) or single (HIV-SRR) group risk reduction conditions or a time-matched wellness promotion (WP-C) group condition

9. Women’s Wellness Study

10. Findings • RCT findings demonstrated reductions of unprotected sex and harmful alcohol use among participants across all conditions, indicating that even low impact interventions can reduce risk for HIV transmission Witte, S.S., Altantsetseg, B., Aira, T., Riedel, M., Chen, J. Potocnik, K., El-Bassel, N., Wu, E., Gilbert, L., Carlson, C. & Yao, H. (2011). Reducing sexual HIV/STI risk and harmful alcohol use among sex workers in Mongolia: A randomized clinical trial. AIDS and Behavior, 15, 1785-1794.PMID: 21739290 • Findings demonstrated reductions in exposure to physical and sexual violence among participants across all conditions, indicating that even low impact interventions can reduce exposure to partner violence in resource poor settings Carlson, C., Witte, S.S., Aira, T., Chen, J. Altantsetseg, B., Riedel, M. (2012). Reducing violence against sex workers in Mongolia: Results from a clinical trial. Journal of Interpersonal Violence. 27, 1911-31. PMID: 22366477

11. Next steps: Seek advice and endorsement from gatekeepers • Debriefing focus groups with Women’s Wellness participants • Consult with project staff and all investigators in country • Consider new direction= microfinance • Planning for pilot and submission of R34

12. HIV prevention and microfinance • Women’s risk reduction is limited by their need to engage in risky behaviors to survive.(Dxxxxx,xxxx; xxxxx). • Need for innovative HIV prevention interventions that target the social and environmental structures that influence risk(Dworkin & Blankenship, 2009; Parker et al., 2000a; Sumartojo, 2000). • Microfinance has been considered as a potentially powerful structural intervention tool in HIV prevention (Pronyk et al., 2005; Parker et al., 2000b) • Several studies have shown microfinance to be an effective structural HIV prevention strategy for women working in sex work (Odek et al., 2009; Pronyk et al., 2008; Pronyk et al., 2006; Erulkar et al., 2006; Sherman et al., 2006)

13. Undarga pilot (2010) – Microfinance Intervention Business Development Training 12 sessions (3/week) Vocational Mentorship Groups 10 sessions (2/week) Financial Literacy Education 12 sessions (3/week) Matched Savings (2:1 up to 576,000₮/425US$) From second week of financial literacy education through end of the intervention Cordisco-Tsai, L., Witte, S.S., Aira, T., Riedel, M., Altantsetseg, B. (2011). Piloting a savings led microfinance intervention with sex workers in Mongolia: Implications for HIV risk reduction. Open Women’s Health Journal, 5, 11-17.

14. Undarga Study design • Undarga is the first test of a savings-led microfinance intervention combined with HIV prevention on reductionsof sexual risk behaviors among women working in sex workin Mongolia • Why not a credit-led approach? • Riskier for vulnerable populations (collateral, interest rate, financial pressure – default, over-indebtedness) • Increase sexual risk behavior • Why a savings-led approach? • Foster asset development • Financial independence without the risks associated with debt

15. Undarga Trial (2010-2013) HIVSRR n=50 3 Month Follow-Up Assessment N=93 IPT Follow-up Assessment n=95 6 Month Follow-Up Assessment N=93 Random Assign-ment n=107 Baseline Assessment n=204 HIVSRR + MI n=57

17. Methods • Targeted sampling strategy in Ulaanbaatar and the peri-urban ger district • 10 sites (including 5 new sites mentioned by participants)

19. Sexual Risk Reduction outcomes • Three key risk reduction outcome variables: • number of acts of unprotected sex in the prior 90 days with a paying partner • number of paying partners in prior 90 days • likelihood to report no risk behavior in prior 90 days

20. Sexual risk reduction outcomes • # of paying partners • All participants exhibited a 31% decrease in the number of paying sexual partners at each time point. Participants in the microfinance group exhibited a 22% greater decrease, compared to those in the control group, for each time point

21. Sexual risk reduction outcomes • # acts of unprotected sex with paying partners • All participants exhibited a 39% decrease in the number of unprotected vaginal sex acts at each time point. We did not find a main effect of the microfinance group, nor did we find a significant group by time interaction.

22. Sexual risk reduction outcomes • Women assigned to the microfinance group were more likely to report no unprotected vaginal sex acts at the 6-months (OR=3.72, 95% CI [-0.37, 7.80]; p=.05). • Women assigned to the microfinance group reported 50% fewer paying sexual partners at the 6-month time point (IRR=0.50, 95% CI [0.31,0.78]; p=.01).

23. Sexual Risk outcomes • Summary • Participation in the microsavings condition appears to have enabled women to reduce the number of paying partners with whom they engaged in sex work and to increase the likelihood that they engaged in no sex work at all by 6 months post-intervention.

24. Economic outcomes • Six key economic outcome variables: • whether or not sex work was the woman’s main income source • the women’s total monthly income • women’s monthly income from sex work • the proportion of women’s income from sex work • overall monthly household income • the women’s share of total household income.

25. Economic outcomes • Proportion of income from sex work • Membership in the microsavings condition reduced the percentage of women’s income from sex work by 78.5 percentage points (t=-2.19; SE=0.35, p=0.029).

26. Economic outcomes • Sex Work as Primary Income Source • Belonging to the microsavings group increased a participant’s odds of reporting that sex work wasnottheir main income source by 3.47 (OR=3.47; 95% CI [1.46, 8.23]; p=0.005). • Women assigned to the microsavings group were less likely to report sex work as their main income source (OR=0.29; 95%CI [0.12, 0.68]; p=0.005).

27. Economic outcomes • Income from Sex Work • Participants in the microsavings group were more likely to report no income from sex work, compared to HIV-SRR group (OR=2.54, 95% CI [1.09, 5.93], p=0.031).

28. Economic outcomes • Total Household and Participant Income and Share of Household Income • Participation in the microsavings condition had no significant impact on the above.

29. Economic outcomes • Summary • Participation in the microsavings condition appears to have enabled women to substitute some of their sex work income with income from other sources without incurring significant reductions in their overall household income, share of household income, or total personal income

30. Summary challenges • Working with a highly vulnerable population • Working with banks and banking services • Competing priorities that reduce women’s ability to save money

31. Challenges: working with highly vulnerable population • Recruitment & Stigma & Risk of Arrest • First session: fear of the known • Regular attendance: alcohol use/overuse, police raids, being injured, getting sick; study site location • Training: mixed groups (low & highly literate); difficulties in understanding of the session due to overnight work • Retention: challenge in staying in touch

32. Challenges: working with highly vulnerable population (cont.) • Mistrust of research team: “too good to be true” • Competing priorities: forfeiting of ongoing accumulation of matched savings due to excessive absences due to everyday priorities (child care, transportation, health-related needs, etc.)

33. Challenges: banks & banking services • Service charges • Lack of passbooks • Identification requirements

34. Challenges: savings-led goals and priorities • Competing priorities and survival needs • Being not able to maintain personal savings account balance

35. Opportunities • First exposure to microfinance • Positive psychological benefits • Increased skills and awareness

36. Case example №1 • “...When I was saving money to pay my debts off, it was difficult to cover daily expenses with the remaining amount. I barely had food on the table for my children to null the debts. Once the debts were paid off, I felt like I saw a dim light toward the end of a hall. Unlike in the past in which I spent all the money I had, today I keep certain portion for saving and spend the rest for only the necessities. Now I save my money with a purpose and have a bank account. I set a goal for myself to attend a vocational training on sewing and to learn how to cut and sew traditional costumes (deel) and other types of clothes…”

37. Case example № 2 • “Before I joined the training, I carelessly spent a lot of my money for sweets, soft drinks and heavy alcohols and wasted for buying unnecessary stuff. Since I had attended the sessions on household budgeting, I started recording daily income and expenditure of my family every day and controlled over the way of spending and avoided unnecessary expenses. I have learnt to save in everything. Record keeping and daily household budgeting has become my habit like brushing my teeth in the morning and the evening. While raising my children, I often used to feel lonely and drink alcohol, but now my life has changed and there are people who support me and the “Undarga” project. Therefore, I’m very confident about myself. I’m grateful to the “Undarga” project…”

38. Discussion • Recruitment & Stigma • Confidentiality • Choice to withdraw from the study at any point • Retention • Follow-up protocols (multiple calls to cell phones, phone minutes incentives and requirement of attendance at 75% of sessions in order to maintain the ability to receive matched savings) • Being close to women’s sex work locations

39. Discussion (cont.) • Banking services barriers • A thorough assessment of banking needs and savings-related services fees • Passbook issue: creating or offering an alternative mechanism or record with essentially the same purpose • Identification issuse: a temporary banking scenario within the project until a woman is able to obtain identification; collaborations and memoranda of understanding between the research team and government and NGO-related services that support identification paperwork should be established prior to initiating the project

40. Discussion (cont.) • Competing priorities and survival needs • Additional research that may allow us to identify for which women such an intervention would hold more appeal, and what may best motivate women to engage, is needed

41. Limitations • Preliminary findings from quantitative reports: data collected from participants during the randomized clinical trial • Process reports: cumulative experience of the research teams from weekly meetings, daily discussion, conference calls and process measures • Secondary aim to test the feasibility of the intervention in order to inform improvements to strengthen the internal validity of the study. As such, our experiences deserve consideration and may inform similar approaches to savings led intervention research with vulnerable populations, but are clearly limited by the approach

42. Implications • Identifying most safe, effective and convenient circumstances for women to attend sessions, and practical motivations that can help women balance survival strategies while they shift their main source of income from exchanging sex to an alternative for of income generation from small business, is required • The qualitative findings related to implementation challenges may help to shape future efforts in savings-led interventions

43. Still needed:Capacity Building • Strengthen ties to University programs in social work and public health • Include local faculty in new projects • Recruit students to do field work internships • Offer training and train the trainer opportunities for local universities and NGOs • Encourage innovation and independent scholarship and grant support (Rule your Life)