Women engaged in sex work (WESW) are disproportionately affected by HIV. In Uganda, HIV prevalence among WESW is estimated at 37%, accounting for 18% of all new infections in the country. WESW experience poverty, gender-based violence, and other issues that reduce their power and limit their ability to negotiate condom use. Female-controlled strategies, including pre-exposure prophylaxis (PrEP), may afford women more transmission protection, but barriers to access and use persist. This cross-sectional study examined baseline PrEP acceptability and initiation among WESW recently enrolled in a randomized clinical trial in Uganda to test the impact of a combination HIV risk reduction and economic empowerment intervention on sexual risk outcomes (clinicaltrials.gov, NCT03583541). A total of 542 WESW from 19 high HIV-prevalent geographical areas were enrolled in the Kyaterekera study between June 2019 and March 2020. Women were eligible for the study if they: (1) were age 18 or over; (2) reported engagement in transactional sex (a sex act in exchange for pay) in the past 30 days; and (3) reported engagement in one or more episodes of unprotected sex in the past 30 days. Women completed a baseline assessment, were tested for HIV and other sexually transmitted infections (STIs) at enrollment, and were connected with antiretroviral therapy (ART), STI treatment, or PrEP, based on need and interest. Descriptive statistics examined baseline data on PrEP acceptability and initiation. Independent variables (i.e. years in sex work, recent sexual coercion, perceived HIV and sex work stigmas, harmful alcohol use, barriers to medical care, and social support) were derived from the empirical literature and women's self-report. Bivariate analysis was performed to test associations between main effects of these variables. Using binomial logistic regression, predictive models were evaluated for two distinct outcomes—PrEP acceptability and PrEP initiation/uptake. At baseline, 59% of women (n = 322) tested HIV negative. Among WESW testing negative, 11% (n = 36) were already PrEP enrolled. Most women reported willingness to use PrEP (n = 317; 91%). Slightly over half of WESW not already on PrEP agreed to initiate PrEP (n = 158; 55%). Logistic regression models demonstrate that acceptability of or willingness to use PrEP was significantly associated with fewer years engaged in sex work (AOR= ·18, 95% CI 0·05-·66, p<·01) and greater perceived social support from family (AOR= 1·39, 95% CI 1·03 -1.88, p<·05). PrEP initiation was negatively associated with greater perceived social support from friends (AOR=·81, 95% CI ·68–0·97, p<·05) and positively associated with higher perceived stigma due to sex work among family members (AOR=2·20, 95% CI 1·15–4·22, p<·05). Despite endorsing PrEP use, many WESW remain reluctant to use it. This gap in prevention practice highlights the heart of a failing PrEP prevention cascade. Findings point to the important role family and friend support may play in destigmatizing sex work and PrEP use for women. Social and structural-level efforts are needed to improve educational messaging and to integrate positive messaging into health promotion campaigns for women and their families, while also working toward decriminalizing sex work. This paper was made possible with funding from United States National Institute of Mental Health (Grant number: R01MH116768).

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.

This study examines HIV/STI risk behaviors, alcohol abuse, intimate partner violence, and psychological distress among 48 female sex workers in Mongolia to inform the design of a gender-specific, HIV/STI prevention intervention for this population. Quantitative findings demonstrate that over 85% of women reported drinking alcohol at harmful levels; 70% reported using condoms inconsistently with any sexual partner; 83% reported using alcohol before engaging in sex with paying partners; and 38% reported high levels of depression. Focus group findings provide contextual support and narrative descriptions for the ways that poverty, alcohol abuse, interpersonal violence, and cultural norms that stigmatize and marginalize women are intertwined risk factors for STIs, including HIV, among these vulnerable women.

Recruiting heterosexual couples into randomized clinical trials (RCTs) to test the efficacy of HIV/sexually transmitted infection (STI) prevention interventions is a challenge that requires innovative strategies and consideration of ethical issues, including participant safety and confidentiality. This paper provides a brief review of the literature on minority and couple RCT recruitment and describes the development (preparation phase and protocol development) and implementation (strategies employed and barriers) of a recruitment protocol that safely enrolled 217 predominantly African American and Latino heterosexual couples into a relationship-based, HIV/STI prevention study. The success of this recruitment protocol with no reported adverse events demonstrates the feasibility of engaging urban minority women and men in RCTs. This study builds on a small literature base articulating specific couple recruitment strategies. More research delineating and testing specific strategies for recruiting defined populations into clinical trials is needed to advance the science of study recruitment and improve generalizability of research findings.