Language
English (en)
Date of Award
8-21-2024
Degree Type
Dissertation
Degree Name
Doctor of Philosophy (PhD)
Chair and Committee
Fred Ssewamala
Abstract
In sub-Saharan Africa (SSA), the estimated population of women engaged in sex work (WESW) is 2.5 million, aged 15 to 49 years (Laga et al., 2023). WESW face numerous challenges, including high-risk behaviors that expose them to HIV, sexually transmitted infections (STIs), drug and alcohol abuse, criminalization, discrimination, mental health problems, and limited healthcare access. Globally, WESW are significantly affected by HIV, with new infections continuing to rise. Recent estimates show that although 8% of all new HIV infections are among WESW, 32.8% of them are unaware of their HIV status (UNAIDS, 2021a). The risk of acquiring HIV is 30 times higher for WESW compared to the general female population (Abdella et al., 2022; UNAIDS, 2021a). Women resort to sex work for various reasons, with poverty being the most obvious. Poverty is a multidimensional phenomenon characterized by factors such as unemployment, low literacy levels, homelessness, morbidity, and social discrimination, all of which are related to WESW. Women in SSA, particularly those 25–34, are among the poorest globally, with 62.8% of all women in extreme poverty living in SSA. Despite increased access to education in SSA, there has been no significant change in the female labor force participation rate, which could contribute to poverty reduction. Limited human capital among women in SSA puts them at a disadvantage in the job market compared to men, making them particularly susceptible to extreme poverty. Most women in SSA in the working age bracket mainly participate in unpaid work, and those with paid jobs are often employed in sectors with lower financial benefits, typically part time. Given the risks sex work poses to women’s health and their sexual partners, the economic empowerment of WESW is crucial for access and control over resources. Therefore, it is important to critically examine and assess economic behaviors in relation to WESW’s HIV risk behavior. This dissertation aimed at examining the effect of an economic empowerment intervention on reducing HIV risk behavior among 542 WESW in southern Uganda. It had four aims: (a) examine the short and midterm efficacy of economic empowerment intervention on the HIV risk behavior of WESW; (b) examine the patterns of savings in relation to WESW’s expenditure and HIV status (positive and negative) among WESW; (c) examine the association between savings, savings expectations, and access to savings institutions among WESW in relation to their HIV status; and (d) Examine the cost and cost-effectiveness of HIV risk behavior change among WESW in Uganda. HIV risk behavior included condomless sex and sex under the influence of drugs and alcohol. Data from three waves of the Kyaterekera study were analyzed. This longitudinal randomized controlled trial assessed the impact of adding economic empowerment to traditional HIV risk reduction methods in reducing new HIV and STI cases among vulnerable women in Uganda. The study enrolled 542 women aged 18–58 years from 19 hotspots in southern Uganda, randomizing them into a control group receiving HIV risk reduction (HIVRR) only and a treatment group receiving HIVRR plus a savings account and FLT (HIVRR+S+FLT). A multilevel mixed-effects model was employed to assess the economic empowerment intervention’s effect on HIV risk behavior. The results did not show a significant reduction in HIV risk behavior among WESW. However, there was a nonstatistically significant reduction in HIV risk behavior at 6 months for those who received the economic empowerment intervention compared to the HIVRR-only group. This pattern persisted when women were grouped by HIV status (positive or negative). Analyzing savings and expenditure patterns among WESW by HIV status revealed that HIV-negative women had consistently higher net savings over time compared to HIV-positive women. Multilevel linear regression models indicated that savings expectations were a significant predictor of increased savings among HIV-negative WESW. The total cost of the intervention was $58,675.70 for the control group and $507,714.69 for the treatment group. The per participant costs using the “treatment on treated” method were $323 for the control group and $1435 for the treatment group. However, the intervention was found to be strictly dominated and not cost-effective. These findings suggest that economic empowerment interventions may not effectively reduce HIV risk behavior among WESW in the short term. Considering longer intervention periods could be beneficial. Additionally, enhancing women’s social support could increase their savings. Incorporating financial support into care programs for HIV-positive women could reduce their expenditure, leading to increased savings and potentially reducing HIV risk behaviors.
Recommended Citation
Kiyingi, Joshua, "Economic Behavior and HIV Risk Behavior Among Vulnerable Women: A Prospective Randomized Control Study in Southern Uganda" (2024). Brown School Theses and Dissertations. 43.
https://openscholarship.wustl.edu/brown_etds/43