*RTI International is a trade name of Research Triangle Institute Satellite Session August 6, 2008 XVII Annual International AIDS Conference The Women’s Health CoOp in South Africa: Efficacy of an Adapted Evidence-Based Woman-Focused Intervention W.M. Wechsberg, W.K. Luseno, T.L. Kline, F.A. Browne, R. Middlesteadt-Ellerson, and W.A. Zule RTI International* W. Gumula, J. Kekana, and M. Masipa Sizanang Research and Development South Africa Sponsored by the National Institute of Alcohol Abuse and Alcoholism, grant No. RO1 AA14488 *RTI International is a trade name of Research Triangle Institute

Research to Practice Where do these women come from and why are they at risk for HIV/AIDS? Adapting the Women’s Health CoOp to the South African context Unique findings reflect the success of the women’s intervention Moving research to practice and policy implications for vulnerable women

Poverty, Minimal and Crowded Housing, and Lack of Educational Support for Women Leads to…

…City Sex work, Almost Anywhere. Pretoria, South Africa

Sex Work Supports Children, Parents, and Extended Family* *Categories are not mutually exclusive

Context for Intervention in South Africa Increasing levels of HIV (29%) among women of childbearing age Young women aged 15 to 24 account for 90% of all new infections Sexual relationships with all types of partners need to be addressed (e.g., clients, main partners, casual partners) Victimization prevalence and incidence rates are high and intertwined with HIV (e.g., the myth of sex with virgins) Health issues related to HIV and substance abuse are intertwined with larger health, race, and class disparity issues from the Apartheid era

Intersection and Paradox: Have you ever been too high on drugs to negotiate condom use? 44% of the women reported yes Women sex workers said… “I use drugs not to be afraid of people because I am shy.” “Drugs give me confidence and courage to hook clients. They keep me alert.” “I think better and can get money quickly – get the edge to look for clients.” *Sunnyside Pilot Study, Pretoria (NIDA supplement 2001)

Adapting the Women’s CoOp to Disempowered Women with Similar Substance Abuse, Victimization, and Sexual Risks? NIDA-sponsored pilot study (2001–2003) NIAAA-sponsored Phase III community-based randomized trial To examine the relative efficacy of a Woman-Focused HIV prevention intervention compared with a Standard intervention Goals for the Woman-Focused Intervention Educate about and reduce alcohol and other drug use risk Educate about and reduce sexual risk Educate about violence prevention strategies Facilitate personal empowerment within a resource-scarce environment

Women’s Intervention Components Biological testing (HIV, pregnancy, alcohol and other drugs) Knowledge Behavioral Skills Training e.g., demonstrating male and female condom use Role-play to improve negotiation and communication skills Personalized risk-reduction plans with specific and realistic goals

Multilingual Pretoria Team

Translated Interventions

Sensitive to Essential Needs: Providing a Bathroom, Meals, and Childcare

Weekly Meetings and Special Cases Mobility, Rape, and Death

Outreach: Where Women Live

The Women’s Health CoOp Pretoria, South Africa (2003–2008) 701 women met the study eligibility criteria At least 18 years of age Used alcohol on at least 13 of the past 90 days Traded sex for money or drugs or had unprotected sex in the past 90 days Provide written consent Provide verifiable locator information 583 women were enrolled in the study and randomized into a Woman-Focused or a Standard intervention group 91% returned for the 3-month follow-up 94% returned for the 6-month follow-up

Selected Characteristics of the Study Sample Non-Sex Worker (n=199) Sex Worker (n=384) Single 0.5% 35.7% HIV+ 33.6% 68.4% Unemployed 79.4% 84.4% Education None to Primary 4.5% 23.7% Secondary 80.9% 72.7% Tertiary 14.6% 3.7% Ever given birth 73.4%

Sexual Risk and Victimization Overall (N=583) Baseline unprotected sex with main partner 80% did not use a condom during last sex act 64% never used a condom in the past 90 days Recent abuse from main sex partner (in the past 90 days) 44% were emotionally abused 18% were physically abused 9% were attacked with a weapon 16% were raped

Outcome: Using Male or Female Condoms during Last Sex Act with Main Sex Partner (N=583)

Outcome: Always Using Male Condom in Past 90 days, Even When High Outcome: Always Using Male Condom in Past 90 days, Even When High* (N=583) *With main sex partner

Outcome: Physical Abuse by Main Sex Partner (N=583)

Outcome: Rape by Main Sex Partner (N=583)

Discussion South African women are vulnerable to HIV through the intersection of substance abuse, gender-based violence, and sex The Woman-Focused intervention is demonstrating effectiveness on the key outcomes Sexual risk reduction with condom use and impaired sex with main partners is a significant finding The Woman-Focused group had better outcomes on victimization by main partner HIV prevalence is extremely high

Discussion (cont.) Non-sex workers and sex workers were 33.6% and 68.4% HIV positive, respectively; medical follow-up is essential Concern with premature deaths Need to reduce barriers and increase access to antiretroviral (ARV) treatment A new partnership was born with Right-to-Care, focusing on ARV for those with <300 T-cell count and giving vitamins to the other women Retesting women who have a negative HIV test result Plans for TB screening, contraception, Pap smear, and STI treatments 

Woman-Focused Projects Outcomes support considering new research projects Possible rollout and replication Government response Adaptation to other risk groups

Research to Action Research to Practice Future Studies and Rollout Right-to-Care partnership (PEPFAR-funded NGO) South African Policy Forum about Vulnerable Women Pregnant Teens Intervention Adapt nutrition and men’s interventions Couples Intervention PEPFAR service proposals with NGOs Proposal for prevention, boosters, and ARV adherence with Right-to-Care

Women will be bringing forth the next generation and … HIV is not the legacy we want to leave them, and it is political for women to have personal power and control over their bodies.