HIV risk remains high among Cambodian female entertainment and sex workers, driven by amphetamine-type substance use and sexual risk. Conditional cash transfer is an evidence-based approach to reduce stimulant use and optimize HIV/AIDS prevention, but questions remain regarding implementation in resource-limited settings. We conducted formative qualitative research to enhance acceptability of a conditional cash transfer intervention aimed at reducing amphetamine-type substance use and HIV risk among female entertainment/sex workers and inform implementation as part of a large cluster randomized trial. We conducted in-depth interviews with 30 female entertainment/sex workers. Interviews were digitally recorded and conducted and transcribed in Khmer. English transcripts were read for emerging themes and an initial coding scheme was developed. Data were coded using open and axial coding to clarify and consolidate initial themes. While most participants expressed enthusiasm for the intervention, financial and transportation issues emerged as key barriers to participation. The proposed incentive of USD$1 per screen was regarded as unacceptable and participants identified a need for transportation assistance. Participants also expressed concerns about directly observed urine specimen collection. Finally, while most participants found the 4-week aftercare program acceptable, the need for enjoyable as well as educational content was emphasized. Revisions to the protocol taking these data into account were made to optimize the acceptability of the intervention and the implementation of the trial. Findings identified key concerns and preferences that were taken into account in the final trial protocol. In particular, financial and transportation issues were identified as critical barriers to participation, with the potential to impact both intervention uptake and trial feasibility. Results demonstrate the value of formative qualitative research for clinical trial planning and implementation, particularly in settings where little is known about acceptability of interventions or willingness to participate.

Engagement in prevention services is crucial to reducing HIV risk among female entertainment and sex workers (FESW), and SMARTgirl is the national social marketing HIV prevention program for Cambodian women engaged in sex and entertainment work. Informed by the Behavioral Model of Vulnerable Populations, three multivariate logistic regression analyses examined correlates of three indices of engagement along the SMARTgirl HIV prevention continuum: (1) receipt of outreach services (past 3 months); (2) being registered as a SMARTgirl member; and (3) SMARTgirl club attendance (past year). Among the 1077 FESW enrolled in nine Cambodian provinces, women working in a brothel or freelance (adjusted odds ratio [aOR] 2.48; 95% CI 1.44-4.26) and those exchanging sex for drugs during the past 3 months (aOR 0.45; 95% CI 0.25-0.81) had significantly lower odds of contact with a SMARTgirl outreach worker. Women who reported having more than ten sexual partners in the past 3 months (aOR 0.54; 95% CI 0.32-0.89) and those who reported binge alcohol use (aOR 0.53; 95% CI 0.29-0.98) had significantly lower odds of being registered as SMARTgirl members. Exchanging sex for drugs was also associated with increased odds of attending a SMARTgirl club (aOR 2.03; 95% CI 1.04-3.98). Novel methods to deliver HIV prevention services are warranted to more effectively reach FESW who exchange sex for drugs, engage in binge alcohol use, report a greater number of sexual partners, and those not working in established work venues.

Background

HIV prevention for female entertainment and sex workers (FESW) may be optimized by addressing individual and structural risks. We examined the impact of a sequentially delivered intervention to decrease sexual risk, amphetamine-type stimulant (ATS) use, and improve economic well-being in Cambodian FESW.

Methods

A cluster randomized stepped-wedge trial was conducted in 10 Cambodian provinces to test multi-level intervention in high risk FESW. After baseline screening in 1198 women, those screening positive for ATS use disorder were allocated to a 12-week conditional cash transfer intervention followed by a 4-week cognitive-behavioural aftercare group (CCT + AC). At six months, ATS abstinent participants were offered a microenterprise (ME) opportunity. Co-primary outcomes assessed in 600 FESW at each 6-, 12- and 18-month follow-up assessments, included: 1) number of sexual partners (past three months); and 2) ATS urine toxicology positive (Tox+) results. Secondary outcomes included indicators of economic well-being.

Results

Relative to baseline, FESW reported fewer sexual partners at all follow-up assessments with a significant 50% decrease at 12-months (Adjusted Rate Ratio [ARR] = 0.50; 95%CI: 0.25, 0.95). Women had 60% lower odds of being ATS Tox+ (Adjusted Odds Ratio [AOR] = 0.40; 95%CI: 0.25, 0.65) at 6-months, and continued but non-significant reductions at 12- and 18-months. Improvements in economic well-being indicators were observed at 12- and 18-months.

Conclusions

Findings support the robust effectiveness of the sequentially delivered CCT + AC and ME interventions for boosting HIV prevention for Cambodian FESW. Further research is needed to inform the scale up and improve durability of this comprehensive approach with FESW in Southeast Asia.