1. 9th IAS Conference on HIV Science
Effectiveness of Comprehensive HIV and Stimulant Use Prevention Intervention with Cambodian Female Entertainment and Sex Workers
Page K, Carrico AW, Stein E, Evans J, Sokunny M, Ngak S, Sophal C, Neak Y, Maher L, McCulloch C.
9th IAS Conference on HIV Science
24 July 2017
Unlocking the Epidemic with Key Populations

2. Conflicts
Funding from Gilead Sciences for research unrelated to this work

3. Young Women’s Health Study -1 & 2
HIV prevalence/incidence:
23%/3.4% (YWHS-1)
15%/1.2% (YWHS-2)
STI: Gonorrhea 7.5%; Chlamydia 11.5%; HPV 41% (oncogenic 23.3%)
YAMA (ATS) use:
Recent 25% Any 40%
ATS use associated with;
HIV Incident STI
↑# of sex partners
unprotected sex
Poor health-services utilization
Background

4. ATS and HIV/STI risk behavior among young FESWs in Phnom Penh - Qualitative
Functionality of ATS in the context of sex work
Yama described as conducive to working long hours and increasing the strength or endurance…, enabling women to see more customers and obviating the need for rest or food
When we use it, it makes us not sleepy. So we don’t sleep and we can get more customers. When I take it, I can make time to sit. If I don’t take it, I would be sleepy and go to bed and have no time to make money. If I use it, I can be awake for whole night. I can sit and serve many customers, one after another (Any, 20 year-old woman).
Women viewed the use of ATS in the context of sex work as functional and conducive to income generation. They described yama as thnam kamlang (power drug) which enabled them to work longer hours.
Maher et al, Int J Drug Policy 2011 4

5. Cambodia Integrated HIV and Drug Prevention Implementation (CIPI): planning and partnerships
Formative research: Qualitative ethnographic research was undertaken to explore views of incentives, transportation, and the CCT+AC program content planned for CIPI implementation.
Planning: National Authority for Combating Drugs, Ministry of Health, Department of Mental Health and Substance Abuse, and FHI360
Local capacity and data informed decisions about approaches and implementation.
Orientation workshops: national and provincial stakeholders, Community-based organizations, participants, and advocates

6. SMARTgirl: Existing program, infrastructure, and leverage
Risk reduction education and & promotion safer sexual practices
Health information and service. Referrals: VCCT, STI & RH/FP
Building capacity and mobilizing stakeholders

7. ATS intervention CCT+AC for SUD
SMARTgirl Plus (CIPI): HIGH RISK WOMEN
SMARTgirl
ATS intervention CCT+AC for SUD
ME opportunity
Health information and service referrals: VCCT, STI & RH/FP and tracking outcomes
Building capacity and mobilizing stakeholders: training and implementation
Expanded outreach; Assessments for HIV, ATS, alcohol and brief risk reduction counseling
Risk reduction education and & promotion safer sexual practices
Health information and service. Referrals: VCCT, STI & RH/FP
Building capacity and mobilizing stakeholders
Outcome evaluation

8. Design: cluster randomized stepped- wedge trial6 12 18 1 2 3 4 5 7 8 9 1

9. Intervention: Comprehensive HIV prevention + ATS prevention + economic opportunityBL
Month 0
OE-1
6- months
OE-2
12 months
OE-3
18 Months
CCT+AC
ME opp
Expanded outreach to engage high-risk FESW in existing HIV prevention services;
WHO ASSIST test with linked brief counseling for ATS and alcohol use reduction;
Intervention for women with stimulant use disorder (ASSIST and urine-toxicology positive) at baseline: 12-week CCT & 4-week cognitive-behavioral AC for ATS relapse prevention;
For ATS toxicology negative women at 6-months: an ME opportunity with 3-day financial literacy training, and optional microloan opportunity.

10. Targeted to high risk women
Inclusion criteria
Biologically female;
≥18 years of age;
Reports >2 different sexual partners and/or transactional sex within past month;
Understands spoken Khmer language;
Able to provide informed consent.

11. Primary sexual risk outcome: # sexual partners in the past 3 months.
Analyses and Outcomes BL
Control
OE-1
6- months
OE-2
12 months
OE-3
18 Months
Primary sexual risk outcome: # sexual partners in the past 3 months.
Supplemental outcomes: # new sex partners, unprotected sex.
Primary ATS outcome: recent ATS use by urine toxicology screening.
Supplemental outcomes: ATS ASSIST Score, Binge ATS use
Analyses to determine effectiveness of CIPI (SG+) compared to SG:
Assess whether the interventions have effects on HIV risk significantly greater than the control/baseline

12. Characteristics of 1198 women enrolled at baseline
N (or median)
% (or IQR)
Age in years (median; IQR) 26
22,30
No. of sex partners in past 3 months (median; IQR) 7
4, 17
Work venue: entertainment
967
80.7
PSA-positive (indicator of recent unprotected sex)
338
28.2
Consistent condom use with paying partners (past 3 mo)
979
87.02
ASSIST Score for ATS
Low (<4)
790
65.9
Moderate (4 - 26)
322
26.9
High (27+) 86
7.2
ATS-urine toxicology positive
286
23.9

13. 6 12 18 1 2 3 4 5 7 8 9 BL
Control
1198
OE-1
6- months
596
OE-2
12 months
544
OE-3
18 Months
566

14. Primary sexual risk outcome: Sexual risk: recent # of sex partners
ARR: (0.38, 1.11) (0.25, 0.95)* (0.18, 1.14)

15. Sexual risk outcomes: supplemental
# of new sexual partners in the past 3 mo.
Unprotected sex: indicated by PSA results
Unprotected sex by self-report: paying
ARR (95% CI)
AOR (95% CI)
Time
Baseline (Ref)
6 Months
12 Months
18 Months -
0.35 (0.17, 0.73)
0.18 (0.07, 0.53)
0.15 (0.03, 0.74)
0.99 (0.75, 1.30)
1.00 (0.69, 1.45)
1.44 (0.91, 2.27)
0.68 (0.46, 1.02)
0.27 (0.14, 0.52)*
0.28 (0.13, 0.64)*
Calendar Quarter
1.15 (0.87, 1.51)
0.93 (0.87, 1.00)
0.88 (0.71, 1.10)
Brothel/Freelance
4.25 (2.62, 6.87)
1.00 (0.76, 1.31)
1.69 (1.21, 2.37)
Adjusted for random effects : province and within subject in province

16. Primary ATS outcome: ATS use: % positive for ATS by urine screen
AOR: (0.25, 0.65)* (0.30,1.14) (0.18,1.07)

17. ATS outcomes: supplemental
Recent unsafe ATS use (ASSIST)
Binge use of ATS (self-report)
AOR (95% CI)
Time
Baseline (Ref)
6 Months
12 Months
18 Months
0.63 (0.33, 1.19)
0.60 (0.22, 1.65)
1.44 (0.36, 5.71)
0.64 (0.34, 1.18)
0.95 (0.35, 2.57)
1.16 (0.31, 4.43)
Calendar Quarter
0.77 (0.60, 0.99)
0.85 (0.67, 1.07)
Brothel/Freelance
29.38 (12.02, 71.83)
7.58 (4.64, 12.39)
Adjusted for random effects : province and within subject in province

18. Conclusions
The CIPI program’s multi-level approach – which incorporated both ATS risk reduction and economic opportunities achieved significant and durable reductions in sexual behaviors in high risk FESW.
We observed reductions in ATS use as measured by urine screening at 6-months, although not sustained. No changes were seen in ATS- related substance use disorder as measured by ASSIST.
Our ATS prevention package included both CCT+AC for high risk users and the ASSIST+BI for all women. Further research is needed to assess scalability and improve durability of both of these approaches.
The micro-enterprise opportunity was novel and the first time that FESW had access to such programs. Adding such programs to existing HIV prevention programs is possible and should be expanded.

19. Acknowledgements
Partners: Cambodian Women for Peace and Development, Phnom Srey Org for Development, Poor Family Development
Cambodia National Authority for Combatting Drug Abuse: Neak Yuthea
Cambodia MoH: Chhit Sophal – Dept. of Mental Health and Substance Abuse
FHI360: Muth Sokunny, Song Ngak, Phou Maly, Len Aynar, Nith Sopha, Hong Naysim, Ean Nil,Srean Chhim A Weissman
Contributions: Y Leyva, M-C Couture, C Dixon
Chamroeun MicroEnterprise; Vision Fund Cambodia
Data Safety Monitoring Board: Paula Lum, Elise Riley, Stephen Shiboski, Frits van Griensven