Human Immunodeficiency Virus Clinical Trial
Official title:
ESTIMA: Economic and Social Empowerment To Increase Upwards Mobility Among Women
The proposed research aims to pilot a multi-strategy structural intervention combining community mobilization to promote gender equity alongside an economic intervention (microfinance and business training) in order to reduce gender-based violence and HIV risk among female sex workers (FSW) in Tijuana, Mexico. The program will be called ESTIMA: "Economic and Social Empowerment To Increase Upwards Mobility Among Women." The evaluation will employ a randomized controlled design, recruiting FSW (n=120, 60 in each arm) who will be randomized to: 1) ESTIMA (gender equity/community mobilization program and economic intervention) or 2) a wait-list control group. For this preliminary work, at 12 months follow-up, we hypothesize that compared to control participants, intervention participants will have: 1) significantly greater economic security (e.g. decreased debt, increased income, decreased number of sex trades) and 2) significantly greater perceived collective power (i.e. collective efficacy) to address gendered power imbalances within social structures and the community. The long-term goal of this program, upon future refinement and large scale implementation, is to reduce HIV risk behaviors, STI/HIV, GBV, and ultimately, alleviate a multitude of health burdens among women. Furthermore, we expect that such work will highlight the need for HIV prevention initiatives in Mexico, and elsewhere, to more broadly consider women's 'life contexts' - addressing economic and social burdens in women's lives, to reduce the burden of poverty, gender, and HIV, as well as the intersection of these among women.
The ESTIMA program will consist of the 1) Via microfinance program, which includes providing
women with monetary loans as a group (approximately 10 women, with repayment as a group) and
training them to initiate a business or other investment endeavor, and 2) gender equity
community mobilization, which involves initiating groups of women (i.e. collectives) and
engaging in social action within the community, with a focus on addressing issues relevant to
gender inequities and women's economic mobility and power (such as client or police
violence/harassment). Like the IMAGE program in South Africa, community mobilization will be
incorporated into the Via microfinance trainings.
Priorities of mobilization efforts will be identified by the ESTIMA collectives, and
facilitated by the election of collective leaders. As part of the microfinance efforts, women
will be provided with a loan of up to $200 each and will support each other by agreeing to
all be responsible to repay the loan as a group. While the amount is small, women can take
out more money with subsequent loans to help them support the business.
The outcome evaluation of ESTIMA will employ a randomized controlled design. From the parent
study (Dr. Brouwer, PI;R01 DA028692), we will recruit at least 120 participants in
expectation to afford a final sample size of at least 48 in each group (using a conservative
estimate of 80% retention). Eligible and willing participants will be randomized to treatment
assignment (ESTIMA or wait-list control group) using a randomizer software package, after
baseline data collection for the proposed research. The wait-list control group will be
provided with referrals to local FSW support organizations, as the standard of care, and will
receive ESTIMA subsequent to the 12 month follow-up data collection. ESTIMA will involve
groups of approximately 10 women each; groups will initiate once sufficient numbers are
enrolled (i.e. groups will be staggered in initiation of the ESTIMA program). Data collection
will include a behavioral survey as well as HIV/STI testing.
This combined program addresses economic vulnerability while also supporting women via
community mobilization to address challenging social conditions at work, in the community,
and at home. This work affords an opportunity to evaluate the efficacy of a
microfinance-based initiative to improve health outcomes among an economically vulnerable
population of women, many who have been trafficked into sex work, and who face dire economic
circumstances to support their families and children. The randomized controlled evaluation
design will be among the first implemented among sex workers and among the few implemented
globally to evaluate a microfinance-based program in terms of improving health outcomes. Such
a robust design will be key to providing evidence needed regarding the efficacy of the ESTIMA
program, and implications of the utility of microfinance as a means of HIV prevention among
this population.
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