A qualitative evaluation of a gender equity and microfinance intervention to reduce HIV risk: Feasibility, acceptability, and impact on economic, social, and health outcomes among women in sex work in Tijuana, Mexico

This study aimed to qualitatively assess the feasibility, acceptability, and impact of Empowerment of Sex workers To Increase social and economic Mobility (ESTIMA; “worth” in Spanish), a group-based, gender-transformative microfinance intervention designed to address economic and social risks associated with HIV among female sex workers (FSW) in Tijuana, Mexico. In-depth interviews were conducted among 25 FSW who participated in ESTIMA. Qualitative interviews took 60 min and were implemented by a trained facilitator. All qualitative interviews were recorded, transcribed, and translated into English by bilingual (Spanish-English) facilitators. Coding and analysis were conducted using a thematic analysis approach. All interviews were independently coded by 2 investigators, compared for agreement, and finalized. The analysis focused on participants’ reports of economic, social, and health outcomes related to HIV risk. Program monitoring data were also compiled (e.g., participation rates, group formation and size). Participants were on average 37 years of age. The majority (66%) were single, 21% were married, with others separated and/or divorced. Participants reported an average of 2.4 children dependents. Feasibility and acceptability of ESTIMA improved after microfinance loans were offered to individuals rather than using the traditional group-liability model, where group members are collectively responsible for each other’s loans. Additionally, groups of 3–5 women were ideal, as larger groups posed scheduling challenges and women preferred meeting with a small number of trusted peers. As a result of participating in the intervention, participants reported increased financial stability, self-appreciation, social support, recognition of their rights as women, and confidence to negotiate health protecting behaviors, such as reducing substance use and increasing condom use with male partners and clients. Additionally, participants reported increased awareness of gender-based violence and felt more confident to address such violence with male partners and clients. While preliminary, findings from ESTIMA underscore the need for structural-level approaches addressing the broader economic and social conditions heightening HIV risk among FSW.