1. *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

2. 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

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

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

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

6. 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

7. 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)

8. 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

9. 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

10. Multilingual Pretoria Team

11. Translated Interventions

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

13. Weekly Meetings and Special Cases Mobility, Rape, and Death

14. Outreach: Where Women Live

15. 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

16. 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%

17. 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

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

19. 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

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

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

22. 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

23. 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 

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

25. 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

26. 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.