welcome to the public health practice grand rounds for january twenty and ten my name is molly mitchell and i'm the coordinator of the mid-atlantic public health training center and on behalf of the training center and the Department of Health and Mental Hygiene I'd like to welcome you to our Grand Rounds this month on given a choice economic empowerment as HIV prevention among sex workers before we begin our presentations I'd like to invite you to visit our website to view our available online
and face-to-face trainings in addition to the trainings available on our website such as public health nursing and the many archive Grand Rounds our upcoming trainings include investigating environmental Public Health complaints trespass warning letters and the law with Bernie Penner on January 28th our core competency training series with dr. Carolyn Fowler continues including community assessment and formative evaluation on februari 19th and professional partnerships and making data work for y
ou on March fifth we're also pleased to offer problem solving for public health with dr. Miriam Alexander on march 10th and for those of you watching online we invite you to email questions for the presenters at any time during this broadcast to ma ph TC at JHS phed you and if you are watching this webcast in a group please take a minute to fill out our sign-in sheet to let us know how many are watching with you so we can have a more accurate count of our online participants and without I'd like
to introduce our two speakers for today first dr. Susan Sherman dr. Sherman is an associate professor at Johns Hopkins Bloomberg School of Public Health Department of Epidemiology and Department of hell behavior and society her work focuses on understanding and enhancing the health and well-being of the marginalized populations such as injection drug users methamphetamine smokers and sex workers dr. Sherman has published numerous articles on sexual and drug risk behaviors of drug users she has
10 years of experience in developing and evaluating social network peer outreach behavioral interventions with drug users both domestically and internationally she has utilized both quantitative and qualitative methods in conducting research in the US Thailand India Russia and Pakistan she is interested in the role of economic empowerment in reducing sexual risk behaviors among women to that end she designed and evaluated a small pilot in Baltimore examining the effects of training drug using fe
male sex workers to make market and sell beaded jewelry she's currently scaling up a pilot targeting sex workers in southern India in which they will make reusable Candice bags to be sold on the Western market our second speaker today is dr. Daniel German doctor Daniel German is an assistant scientist in the department of health behavior and society at the Johns Hopkins Bloomberg School of Public Health her research uses qualitative and quantitative methods to understand and address the social c
ontext of health behavior with particular emphasis on issues related to urban health HIV transmission drug use and mental health she has extensive experience with harm reduction program implementation and intervention development her current activities include a focus on HIV behavioral surveillance zoning and the public health impact with social economic and housing stability with that I'd like to present you with dr. Susan Sherman thank you Thank You Molly thank you for being here today physica
lly those who are here physically and those here here virtually so our talk is entitled economic empowerment as HIV prevention what does money have to do with it and we're going to be talking to you today about two studies one that took place in Baltimore and finished a few years ago and one that's ongoing in Chennai India so I want to start with a little bit of context to talk about HIV risk among sex workers like many other populations research is primarily focused on individuals devoid of con
textual factors that's not a bad thing but it's not necessarily a sufficient thing to understand the complexities of risk and I think it makes a lot of sense why we study individuals it's easy to get individuals and studies we often see short-term behavior change but it doesn't really kind of create long-term change if you think intrinsically about condoms has been the biggest intervention with sex workers while that's very important because it is a very effective way to prevent HIV how women ge
t men to use male condoms is a whole nother issue that has a lot of factors that influence it female condoms also have been shown to be effective but they're more complicated they're bigger they're not as distributed as widely and among sex workers if you think about the risk whether they use drugs and need money for drugs economics really play a role so in thinking about what would cut the risk at its source one answer is money lisset income I want to reiterate that I think it's really importan
t and I continue to do research on individuals and it's necessary but it's not sufficient and explaining why people place themselves at risk and how we can intervene in a sustainable way and what oftentimes is unaccounted for and a lot of the studies which we do because before the last few years we haven't had G is available we haven't had all these great datasets that explain neighborhoods for examples one thing that's really been unaccounted for is the broader relationship and structural facto
r that shape women's risk that some x economic policies that seem very distal may indirectly have an impact and that's hard to study that's hard to measure so we posit that context really counts and epidemics follow society's fault line so when you don't have a healthcare infrastructure I mean a horrible example of course has been Haiti which is on all of our minds without building codes catastrophes happen an HIV unfortunately for the past 20-plus years is a horrible example of that that the HI
V epidemic really has settled into low-income countries to low-income populations within wealthy countries like the United States and throughout the world fairly consistently poverty characterizes HIV risk although it's much harder to intervene on that distal factor of poverty all right so I think it's important just to say that poor countries are more likely to have general epidemics HIV epidemics and countries with more income disparity why the US has higher prevalence estimates of HIV among s
ubpopulations compared to Western Europe some of it a tribute of that to the disparity between the wealthy and the poor and these are really hard issues to kind of focus on structurally whenever I give this talk I think it's important to say everything I'm calling risk behaviors and the lives of the women who day-to-day need to feed their children pay this children's school feeds fix their you know meet their drug habits it's really coping mechanism so I as an epidemiologist social scientists wi
ll use the word risk behaviors but in the data life of a woman they're making choices that actually benefit them in the moment and I think that's important to acknowledge so to take a step back a structural intervention because I've been talking about structures is an intervention that actually targets the political legal physical social environment and not necessarily the individual themselves so some examples are that is if you have drug paraphernalia laws drug paraphernalia laws that were cha
nged so that people can carry syringes who go needle exchanges that's a that's an in that's an environmental change that actually reduces risk and HIV prevalence at an individual level things like seat bella's which actually mandates a behavior change that has been shown again it again to not only is it and we can I can't imagine getting in a car without putting on a seatbelt but it actually greatly reduced traffic fatalities or programs that are aimed to reduce poverty is another example of the
structural end of attention like the Grameen Bank microfinance interventions and what Danielle and i'll be talking about today is somewhat of a version of a micro-enterprise intervention so with that I'm going to turn it over to Danielle to talk a little about about the work we did in Baltimore with the jewel study hi um so it's my privilege really to talk about a project that we worked on together a few years ago and it was here in Baltimore among drug using women called the Jew in your home m
uch more about that but first this is Baltimore this is the Baltimore that many of us know quite well it shows the gleaming Harbor it shows the big tall buildings and this works really well for the visitor center to be able to promote what it is that's good about our city this is also Baltimore and this is a Baltimore that is quite real for a very large percentage of our population and what you see here are abandoned buildings see not a lot going on you see trash in the street and you see kids g
rowing up in a neighborhood that doesn't have a lot to offer and I think the combination of these two pictures really gives a sense of some of the stark disparities that exist in the city particularly economically and this gives a little bit more detail about the socio-economic context here in Baltimore and what you see are the unemployment rates for Baltimore on the top line and then compared to the United States and to Maryland over time and like most other places Baltimore recently has had qu
ite a spike in unemployment but if you notice Baltimore has been here before and we actually have quite a legacy of unemployment and this is not a new thing and it's been with us for a while so currently our unemployment rate is about eleven percent there's an additional 35 approximate percent of people who are considered not part of the labor force at all these are people who are not working and they're not currently looking for employment for a variety of different reasons thirty-five percent
of the population earns less than twenty-five thousand dollars a year about twenty percent fall under the official poverty line and then about a third have less than a high school education so these are complexities that just add to the overall sense of economic challenge that exists in the city Baltimore also has some of the highest rates of heroin use and a quite substantial level of crack use as well and for drug users the socio-economic context is perhaps even slightly more complicated so dr
ug users live in um tend to live in conditions of very severe economic disadvantage also have very low levels of education and their job opportunities are limited similarly to people who don't use drugs but additionally they face some specific barriers to employment and this includes generally our limited level of job preparedness additional complexities to working due to challenges with addiction or with maintenance of drug use and then specific barriers to participation in job training program
s to participation in certain sorts of jobs that will require a drug-free environment that just makes it very difficult to maintain a steady source of income and then couple this with standard financial need as anybody has to maintain their family to maintain their housing that sort of thing and the very real costs that are associated with using drugs this creates a circumstance of relatively challenged bargaining power and when you think about HIV risk particularly for women wear it comes down
to being able to convince a male partner to use a condom when that male partner is somebody who contributes to their rent and their bills or is somebody who is choosing whether or not to pay whether based on whether or not a condom is being used then the the possibility of HIV risk reduction is quite compromised in that sort of context so this shows that train of thought I'm a little bit more clearly and so what you see is that the limited job opportunities coupled with specific barriers to empl
oyment create a quite constrained economic context where in reality the most viable economic options for drug using women in particular drug users overall are engaging in sex exchange behaviors participating in the drug economy whether selling drugs or other roles within the economy or various hustles which have varying degrees of legality in the combination of these each one of them has some degree of very likely increased risk risk specifically of for HIV risk of incarceration and risk of cont
inued and increased drug use which then starts the whole cycle all over again so it was with this all in mind that we initiated the jewel project and jewel stands for jewellery education for women empowering lives and you see you'll see much more detail about the project but what you see here is just one of the community sales that that was to market jewelry from the project so the study aimed first to assess just the feasibility of training drug using women how to make market and sell jewelry t
his was a very new idea this is a pilot study just to see if it was even possible and worth doing on a larger scale we wanted to see what the impact was of a program like this on women's feeling of readiness to participate in a formal job and then to look at the impact of jewel on HIV risk taking behavior so why jewelry making of all of the different things first lots of people like jewelry it's an easy thing to sell you don't have to sell it for all that much but lots of people like it and you
can find a pretty broad market for it it's a pretty easy thing to start up you need some beads you need some string and you need a few other supplies but it doesn't really take much to get going it's an easy thing to learn it's an easy thing to teach and then you are it takes a pretty short time between when you first learn it or when you start doing it and when you have something that is easy that is possible to sell so all of this contributed to the decision of jewelry making the project took
place over about a six-month period ending in june of 2003 and you'll see a lot of our assessment and we did a survey at baseline and then we did a survey three months after participation with the project ended the women that we invited to participate were recruited through targeted outreach particularly at a local community based organization the syringe exchange and other research studies and we ended up with 66 women who completed the survey 54 women ended up participating in the project the
participants were required to be female they were over 18 and within the past month they had traded sex for money or drugs and reported using heroin or cocaine at least once a week for the past month and then you see a little listing of some of the items that we talked about in the surveys but you'll see much more of that as I go on so the intervention um it consisted of six two-hour sessions it was facilitated by an individual with strong art background and also really strong training in harm r
eduction which is just a general premise that of non judgment and that small really any positive change can be favorable and can be useful in people's lives the project was located in a storefront in a high drug-using neighborhoods we were right in the midst of people's lives and I'm gonna skip ahead to tell you show you what the sessions were so the first three sessions were it was we met weekly first three sessions were divided half and half between Risk Reduction and jewelry skills building a
nd opportunities for jewelry making and so um the risk reduction content of those first three sessions touched on a variety of different drug and sex related risks and then that was followed by specifically how do you make a bracelet how do you make a necklace how do you count out what beads go where and what do you think if you're thinking about proportions of of you know size of bead what are some of the considerations so literally how to make jewelry how to do a fasten and then time for peopl
e to design and create their own jewelry the fourth session then was a specific session on preparation for a sale on how to market on pricing and then more opportunity for people to continue working on the jewelry that they were creating the fifth session was a sale that took place off site and then we brought everybody back together to do a review to talk about next steps and to have celebration for graduation and then throughout we had once weekly open jewelry making sessions that were open fo
r anybody who had participated in the project throughout the period of time they could come in continue working on the pieces they were working on start new and that kind of thing so the session the sales sales were wonderful and you see some of the pictures of this on the side we did one sale for each cohort that took place at the outpatient center here at Hopkins and then we had throughout the period of the project we had for community sales that were just for everyone and the women were invit
ed to be to come to the sale and to be a major part of the salesmanship and they dressed up and they showed up and they you know they brought people to the table they talked about their work we talked about the program and that kind of thing the way that the pro seeds were divided it was the the jewelry pieces were priced relatively competitively maybe on the lower end of the scale but competitively fifty percent of the sale of each item went back to the jeweler who made that particular item thi
rty percent of the overall sales were divided among the participating women who participated in the sale itself and then twenty percent went back into the project for supplies so before I show you some of the changes that we saw I just want to give you a picture of who it was that was participating in the study and the project was or the participants were about sixty percent african-american about a third had completed high school about a third had been homeless in the past three months forty pe
rcent had been in jail in the past three months and you can see that eighty percent had been in jail at some point in their lives um seventy-five percent had children in their home at currently about ten percent where HIV positive and about twenty percent had participated in a job training program at some point so then we looked at a variety of different things to see what was different from when people started the program versus when the immerses three months after they finished and what you'll
see as I'm going through the bolded items are the things that that changed and worse those changes were statistically significant so as I mentioned one of the eligibility criteria that people were required to have participated in sex exchange for drugs or money so everyone at baseline had had participated in that but it follow up 71 percent had so it was a thirty percent reduction there and then there was also a statistically significant drop in the percentage of people who reported being invol
ved in the drug economy or having specifically sold drugs and we looked at drug utilization patterns from the start until three months after and what we saw was that daily the proportion of people who used drugs of any sort daily was significantly reduced there was a significant reduction in daily crack use among the the I would say that most of the the women were crack smokers some were also injection drug users but there was a reduction in daily crack use there was a reduction in the amount of
people who were engaged in injection drug use and then interestingly we asked people how much they spent on drugs in a day sixty-five percent reported that the that they reduced the amount that they spent on drugs from the beginning until the end and this reduction ranged from about five dollars to up to two hundred dollars and on average the the midpoint of the amount of money that people spent on drugs per day was reduced significantly from $53 to about forty seven dollars and then we looked
at any change in sexual risk behavior and what we saw was that the average number of sex partners per month significantly reduced a number of sex trade partners reduced and then we also saw an increase in consistent condom use with specifically we trade partners although we didn't see the significant change with steady partners and which is somewhat to be expected and we can talk a little bit about that later um so a little more detail about what pieces of the program may have contributed to som
e of these changes that we saw most of the women participated in all of the six sessions close to half attended one at least one open jewelry making session and notably there they've received no personal compensation for attending the the jewelry making sessions those were just available for them and at the open sessions we saw about an average of five people and they the combination of who it was that attended really buried from week to week / 11 sales that we had over the six-month period the
net jewelry sales totaled seven thousand dollars which is quite substantial seventy-seven percent of the women sold at least one piece and among the women who sold at least one piece you see is the midpoint of sales was 164 dollars the smallest amount of money that someone who sold a piece made was twenty-nine dollars the most amount of money that one of our participants made was 1231 dollars and I'll say that that was a particular rock star who was part of the study who just really took to it a
nd adopted it as a really wonderful thing for her but there was a there was another person who made a thousand dollars there was another person who made five hundred dollars so this is an outlier for sure but it's not entirely inconsistent with other women's experiences in the project so then finally we looked at factors that were associated with change in the number of sex trade partners from the beginning of the study until three months afterwards and the short version of this slide is that we
found that the amount of money that people made from the jewelry sale was significantly associated with a reduction in the number of sex trade partners to the extent that we could see that women who earned a hundred dollars from jewelry making had eight less sex trade partners at follow-up compared to baseline and that's in a short period of time that's actually quite good and if when you start talking about the likelihood of exposure to infectious diseases the fewer people that you're in conta
ct with the better the better your likelihood of exposure is so what can we say from all of this one certainly that women were interested and quite successful in jewelry making we did see some reductions in HIV risk behaviors this was a unique study it offered us the opportunity to see whether this was feasible and it did seem to be feasible joel was not intended to be a job training program it was intended to be a supplement an economic supplement and I'll say that while for some I think that w
e certainly demonstrated that that it achieved that but additionally I think for some people the participation in the project felt like a bit of a taster for later participation in the job market but we certainly acknowledge that there is absolutely a need for formal job training and job opportunities that are amenable to the circumstances that these women's lives allow limitations certainly this is a small sample it was a relatively short follow-up this is a non random sample so there may be so
me bias involved there and there was no comparison group so we can't specifically tease out what pieces of the intervention may or may not have been helpful but we have some thoughts on what what may or may not have worked so well and what I want to leave you with are some of the things that we learned doing this this project that for future implementation seemed really worth considering going forward and one of those is that the open jewelry-making said that I would say the jewelry making sessi
ons in general and particularly the open ones where people just kind of came in on their own time and joined us were absolutely safe zones there were times when women could come into a space that they perceived as safe as quiet as removed from their everyday life focus on making something that was important to them that there that was beautiful that they could be creative that they were surrounded by people who were supportive was a really wonderful opportunity for the women that they really the
y valued and they continued to enjoy would say that the the path the group aspect of it was was quite important as well where the the women certainly came to know one another they experienced things and were able to process their participation in the project be with others who were experiencing it similarly and having circumstances going on outside and they could support each other they could remind each other that a sale was coming up they could help each other get to wherever they needed to ge
t to so that was really valuable um different women responded to different aspects of the project um better than others and so there was there were aspects of jewelry design there were aspects that relied on marketing there were there was you know the actual stringing of the beads onto the jewelry some people were better at different parts of that than others and I think that future implementation would ideally try to figure out ways to support people in whichever pieces they were most drawn to
and so whether there's a track system or sort of tiered implementation I think there's a lot of possibility there and similarly the structure versus creativity aspect we set things up so that women could they did all of it they designed their own jewelry they decided what colors they wanted which beads they wanted to use and then they did stringing and they created the the jewelry themselves this didn't really work for everybody not everybody liked all of the pieces not everybody was good at eac
h of those different aspects and that affected their likelihood of sales and economic generation later on so i think that future implementation certainly could could take some lessons there and try to figure out the best way to balance the creativity versus the ability to create something that that does have a good market um sales and marketing should not be underestimated in a project like this I'm keeping track of inventory figuring out what is the most appropriate market making sure that the
that the items match the market and that the the venues are suited all of that just takes time and attention and finally I want to say that um sustainability is something that maybe we can talk about a little bit afterwards I think it's it's always a consideration for projects like this and for a project specifically like this something the economic empowerment type project it's not just about sustainability of the program but it's about sustainability of that economic opportunity and so it beco
mes not just you know can-can the support structure exists but is it something that people can actually see as something viable for them to continue to create an economic alternative for them in the long run so I think there's a lot to be able to consider there but I just want to acknowledge the funder for this as well as some of our fantastic staff members Marie Marcy Diane Eddie Charles yen chi and Morgan and Anna Leary and then without a doubt the really wonderful women who were part of the p
roject that I will turn it back over to Susan learned in Baltimore and applied them in chennai india a lot of i mean even just listening to a lot of the things that we around marketing and design we actually are right now with the help of stacey widely who's the head of the pi foundation we're helping to implement and explore in this study in india that I'm about to tell you about so chennai is in southern india this is chennai you can see it's in the state of Tamil Nadu on the south east of ind
ia and this is a picture of chennai it's 70 square kilometres 70 million people and during traffic it takes forever to like two hours to get from one side to the other it's um quite amazing and that we always relate to every meeting when we're driving somewhere because traffic is really hard to predict and it always takes longer so the aim of this pilot study was to once again similar to jewel examine sex workers ability to be trained and sewing and produce sellable products and to the Explorer
the expects effects of the intervention on sexual risk behaviors which is involvement in sex work and also their overall economic well-being the study was a hundred women so we had more funds than the jewel pilot to be able to have a hundred women who were randomized into two arms they were all Street Bates based sex workers who were recruited from venues such as train stations open air markets the beach etc so they were Street based there were two arms of the trial the first was for sessions ei
ght hours of HIV prevention kind of cumulative things that I learned from when I was a doctoral student with Karl aachen and started doing behavioral interventions through work that I've done with him in Thailand and elsewhere so very interactive facilitators with a manual and then the second was the same eight hours of HIV prevention plus a hundred hours of tailoring training tailoring training we actually started out with 40 hours of training but it wasn't enough and so for the products we cho
se which will show you so we needed a hundred hours of training taught by master tailors and data were collected at baseline three and six months and today I'll show you the six-month baseline it's important to say that the street based sex scene the women who work on the streets are very different in chennai then i think what you think of in your head for sure different than the women we worked barring the drug the drug use was an obvious different with the women we worked with in baltimore wit
h jewel these women in india many of them are married they have children they work during the day their husbands I think are mostly in denial about what they do their husbands a lot of them drink and extra money is needed for school fees so for us the best times to recruit we're actually business hours it wasn't late at night there of course are women on the streets selling sex late at night but the most of the women in chennai at these various outdoor venues are and they look like you'll see a
picture at the end they just look like any woman you see on the street of india and they are and this is an opportunity this is one of the few opportunities they feel that they had so the median age there there actually were no significant differences between the two arms they were an average of about 34 it's interesting in both jewel and in pie it was older women even though it was open to women over 18 it was the older women who are more interested they have less clients fewer clients there I
definitely think their bargaining power is more compromised because they're older and then computing with 20 year olds on the street so a lot of these women also are kind of primed for change as well we're hoping in our next study i'll talk about in chennai that we're going to try to recruit some younger women to see if we actually can affect change in that way as i said the majority were married they had children and the median age of first sex was 18 quite late relatively speaking and most of
it was largely with their husbands once they were married so it's really kind of a different portrait of what you think these are some of our participants actually was just in Chennai with Stacey on the woman on the left is a master tailor who still with us working now and those are you can see when we're working on three of the seven industrial machines we have which is very exciting okay so we looked at differences between baseline and follow-up first this is about looking at comparisons in in
come we were pleased to see that people earned about thirty-three percent more at 6-month follow-up the women in the tailoring arm compared to control arm these are all significant differences and women in the control arm women in the tailoring armed earned about forty percent less from sex work so they direct they reduce the the sex work which we could see also in the average number of clients and the proportion of income from sex work was reduced that of course makes sense since they were maki
ng money from selling the bags women were paid to be in the intervention and they also were paid when they continued in the intervention per bag so the proceeds actually went to the women / sellable bag and I'll talk a little bit about where we saw the bags and this this comparison is from after they finished the training so we're talking about once they were done not being paid the hundred hours because that's obviously a lot more money 108 hours compared to eight hours this is actually just th
eir average monthly income in the six months after they were finished with the intervention all right then that's just something to highlight I think it's important to show the big difference and this is looking at in the presence of other variables baseline age and also baseline income women in the intervention arm had an average of two less sex parade partners per month and that was something we were happy to see if you want to ask me a little bit about these numbers are lower than we expected
and there's a lot of interventions going on in India lots of gates money that reach this population and I think that we probably had women who had in general were previously exposed but I'm happy to talk about that later but regardless the reductions in sexual risks went in the direction that we wanted in also the direction of income per month went in the direction that we were hoping so over all women are interested in learning new skills and willing to work hard and we think that inner interv
entions such as this that actually address issues for us it was I mean it was obvious it was an HIV prevention intervention to them because we had those sessions but we also spoke to something else that stresses them out every day much more than their HIV risk which is how are they going to get money to pay their kids school fees that was always the example that came up so I think people appreciate that when you actually address the needs of their lives in a way that's kind of beyond disease con
trol which is a priority for us so I think it's a mutually beneficial it was a mutually beneficial intervention so to talk a little bit about bag production and sales the bags were actually all sold in the US by a nonprofit that we set up the pi foundation we have some samples today some new designs we'd be interested in your opinions about that car lock and just brought back to us from India that were just made so Stacey here has the bags and afterwards if you want to see them we love your thou
ghts on some new designs and sixty percent of the women continue to make bags today so that is eight months now it's nine months post the study being ended we've sold 4,400 bags in 11 stores at three conferences we had an event and also through internet sales and our we're very excited that we're actually producing the bags for the global health conference this year 2100 bags as soon as she sends us the logo which she knows of concern cuz it's we yeah we have like three months to do that but any
way it's very it's very exciting that we have that's our biggest order yet so we started making bags this tote in october two thousand eight and i have to say and it was probably the worst thing we picked as a first bag the materials so heavy i mean i was partially to blame it's so complicated the stitching is really hard and that's likely why we needed a hundred hours of training for the next study we're doing we're starting off with a few much simpler products and this was a big lesson learned
from jewel that it's really important obviously not going to have women designing the products but we even we needed to be better at knowing what matching the skill level women feeling good about creating something and not getting frustrated in April we introduced and our sales were kind of slowly continuing a lunch bag and the best thing we thought of and I attribute it in part to my liking of wine was to actually make a wine bag for wine stores that have there's the store logo on it and this
is when the sales really skyrocketed because our orders have been 500 + 650 bags at five different stores this example is a six pack wine bag for the wine source which is in hamden and I promote if you want to support pie it's a great place to buy because they actually are donating all of the proceeds back to us which is really fantastic alright so every bag that's the wine bag on top and another tote bag that comes in different colors with different fabrics every bag actually has a logo we have
this is the logo that goes in the cotton bags because it's not organic the material that we use for the wine bags but we have another logo because we always want to promote the social cause of aspect of this project it's about environmentalism it's about women empowering women it's about HIV prevention so today as I mentioned we have the pi foundation which is housed in Baltimore we continue bag production we're developing business plans marketing plans we have lots of angels and volunteers who
help us in this process students who are doing this for projects and hopefully we'll be able to pay other people to do these things as well we just received a great score on an ro1 that hopefully when we get approvals will start in the spring summer or fall and it actually is going to be 500 women that are going to be randomized half and half to a hundred hours of English and a hundred hours of tailoring so we're happy that we have the funds now to actually do a true attention control and the f
ollow-ups will be as long as 18 months I think it's really important to end with the voice of one of the women in the studies and not my voice even though i'm going to talk through your reading this this is aisha is 35 years old she was one of our pilot participants we did some tative interviews at the 6-month follow-up and she's been in sex work for five years and she felt she had to her husband drank they had no money her son she had to stay home actually because there wasn't there weren't fun
ds for him to go to school which he needed to go to school so she had to make this choice to go into sex work and as she said if pi delivers what I'm hoping it will maybe I can tell my other friends to trust me there's so many women out there who are hoping for a new life will come their way I want to acknowledge nmi to funded our pilot of course the women of pie and pie staff we collaborate with a fantastic organization in India that runs this whole study yrg care particularly my colleague Chri
s who has worked the way through and Stacey and Catherine who run the PI foundation and I want to leave you with an image we took a few weeks ago of women and Frankie feelin noticing there smiling they don't always smile for photograph this was the smileys photograph we took and if you're interested to see more about the project visit our website thank you thank you very much Susan and Danielle it was a fantastic presentation at this time we do have an opportunity for people to ask questions QA
both live for people who are here as well as people who are watching online and if you are watching online please email your questions to our email address at ma ph TC which stands for mid-atlantic public health training center at JHS phed you so and while we're waiting for our online audience when we go ahead and yeah right here sure everybody feels the way I do this is so cool and it's wonderful year about and I have a question this seems oh thank you that seems very obvious to me that this wo
uld work and I'm not surprised by your results what I'm wondering about is broadly in the public health field and with the funders is this easy to promote our people buying it I will say that we had wanted to expand top the jewels study to be a large trial and I think rightfully so we never convinced the study section that we could do that we could sustain sustained women in this type of endeavor make enough money to sell jewelry so it took you know really from two thousand three two now to be a
ble to do this and I think our thought processes develop but the time is really ripe for structural interventions in the HIV world so that's one thing as far as bag sales which is a separate issue if you think we can sell enough to sustain women there's no doubt especially if I mean we're hoping we have the capacity in a few years to make the bags for the AIDS Conference which is 35,000 bags I don't know if we're going to be to that point but since we have different markets wine stores which the
re plenty of conferences etc and as our website gets out we hope that we're going to be able to actually be self-sustaining it's why business the business part of the side of this project is so important because absence of funding from the NIH in five years we're really hoping that we will be self-sustaining as an organization to the two more quick questions do the women do any work with budgeting not at this point not at that point and do see this coming back to Baltimore it's a good question o
k I want to say that we actually did sustain the jewel project in Danielle and I were both into currently involved with the rock star whose name is who sadly died a year and a half ago she started an organization called gifts encouraging and motivating sisters gems of hope and so we continued even though we couldn't get funding do a bigger study we both worked very closely with with this nonprofit lots of mistakes were making lessons mermaid lessons were learned but we actually tried to make it
sustainable the jewelry part here with us advising this woman who just took to bead making like nobody's business okay I have two related questions but first thanks for a terrific presentation in your work is fabulous so one question is are there resources available in the ro1 grant to make each intervention available to the women who participate in the other one at the end of it like the English training and the tailoring training in on a related point is it possible to think about collaboratin
g with microcredit organizations to to sort of scale up the availability of this training a great question we actually not to the English so the 250 women who graduate from English all will have the opportunity thanks i will have the opportunity to then be a part of be trained in bag making we didn't think of reversing it the more important thing for us because we hypothesize that they'll benefit more greatly from being involved in the bag making we're opening that up to everyone we have funds f
or that after they're finished with their 18-month follow-up the second question is we actually are going to do 10 hours of training on social entrepreneurship for the women in the RCT we think 10 hours that we will be enough to start women on budgeting and savings and financing and we're actually working with someone who works at a microfinance organization in Chennai that will help guide us on that process but yes if this could be scaled up much bigger but this is what we're doing now because
it was so hard to kind of contain it just as you know and what we came up with was training people and tailoring Chennai also mean half the percentage of the clothes in this room were likely made in India and could have been made in a factory there's in Chennai so just like Danielle talked about in jewel we wanted to spark people to actually see themselves doing something positively and making money and being proud of how they make money we don't expect everyone's going to keep making bags that
are shipped off to the US they may go make clothes or something else well I'm glad to hear you say that they can kind of move on to make clothes because that's kind of where my question is going because I heard you say that obviously we wouldn't have these women designing bags on their own so my question is is it is it possible for these women to sustain themselves what potential is there for these women to sustain themselves outside of the intervention without the assistance and support of the
pi foundation so that's a great question and my comment really spoke to in the beginning part of I think what we failed and jewel was thinking that everyone could come up with the design from the first time they made a necklace so obviously we wouldn't expect women to come up with designs the second that they got their hands on the material that's what I meant we've absolutely actually one of the women the color combination of a bag that we just I haven't even seen them yet that just got brought
back from India was recommended by one of the women who's been working with us for a year and a half so as people we're really trying to figure out where the collective aspect can come in and it's a conversation we're having how do you have this standardized you know randomized trial and then how do you actually give women some autonomy and not just have granted it's in it's an industry an endeavor that's created for them but we want them to have some control so some of the pilot participants a
re going to be peer managers in the in training etc we're hoping to involve them in that way and that will evolve over time is that it ok ok just a reminder for people watching online our email address is ma P HTC the Atlantic public health training center at JH SPH edu any other questions here in the live audience there are speakers no ok well then that is it for today's public health practice Grand Rounds I want to really thank everybody for coming and especially a big thank you to doctors Ger
man and and dr. Sherman thank you you
Comments