Program Profile: Women's Health CoOp (Pretoria, South Africa)

This is a woman-focused, HIV intervention designed to reduce sex-risk behavior, substance use, and victimization among at-risk and underserved women, including female sex workers. The program is rated Promising. Compared with the comparison group, non-sex workers in the intervention reported less sexual abuse, alcohol use, and verified drug abuse, and sex workers in the intervention reported less physical abuse and verified drug abuse. These differences were statistically significant.

A Promising rating implies that implementing the program may result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

A Promising rating implies that implementing the program may result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Goals

The Women’s Health CoOp (WHC) in Pretoria, South Africa, is a woman-focused HIV intervention designed to reduce sex risk behavior, substance use, and victimization among at-risk and underserved women, including female sex workers and drug users. The intervention aims to help women (1) increase their knowledge about alcohol and other drug use associated with sex risk and gender-based violence; (2) reduce substance use; (3) improve communication skills with their partners; (4) increase condom use competency; and (5) learn about specific violence prevention strategies.

Program Theory

Research has begun to document and examine the interplay of HIV, substance use, and gender-based violence and victimization among women in South Africa. For instance, there are large disparities between men and women in South Africa in terms of income, education, housing, and health care. Many women are poor, uneducated, and lack adequate job skills. To survive, many women resort to sex work. These activities can expose women to sex-related violence, which can lead to higher rates of alcohol and other drug use to cope with the stress and anxiety associated with sex work. Alcohol and drug use can, in turn, increase the chances of women having unprotected sex, which leads to a greater likelihood of contracting HIV (Wechsberg et al., 2005).

The WHC is an intervention designed to address the intersectional nature of these issues. It was based on principles of social cognitive theory (i.e., sought to enhance skills and increase self-efficacy), gender theory (i.e., focused on stress women face, sexual assertiveness, and power imbalances in relationships), and empowerment (i.e., focused on feelings of powerlessness and economic dependence on male partners) (Wechsberg et al., 2006).

Target Population/Target Site

The WHC intervention was designed for female sex workers and at-risk women 18 years and older who used alcohol or drugs and lived in Pretoria, South Africa. Pretoria was selected as a target site because it is in Gauteng, a province that has particularly high levels of hard substance use (e.g., cocaine and heroin).

Services Provided

The WHC intervention was adapted from a woman-focused HIV prevention intervention that was delivered to African American women who abused crack cocaine in the United States (Wechsberg et al., 2004). The program was adapted for use with Black South African sex workers who used cocaine and were at high risk for HIV and other sexually transmitted infections (STIs). To adapt the original intervention, in-depth interviews were conducted with service providers, researchers, and female sex workers in Pretoria to obtain a better understanding of risk behaviors and determine appropriate ways to address those behaviors within the context of a South African woman’s life.

The woman-focused intervention in Pretoria is culturally specific and focused on contextual issues (e.g., sex-related violence, substance use, and cultural barriers to increased condom use) and lifestyle issues (e.g., multiple sex partners) that are relevant to sex work in South Africa. A key element of the intervention includes increasing knowledge about women’s particular risk for HIV and other STIs, substance use, and violence. The intervention includes a personalized assessment of each woman’s drug and sexual risks in order to develop concrete short- and long-terms goals that the women feel they can attain to reduce sex risk, substance use, and gender-based violence.

HIV education was tailored to increase factual knowledge and dispel myths about HIV, AIDS, and sexual practices (for example, two male condoms are not better than one, and sex with a virgin does not eliminate the chance of HIV infection). Women are provided with information on HIV; drug and sex risks; risk-reduction methods such as proper use of condoms; how to talk to a partner about safer sex practices, including condom negotiation skills to reduce sex risk; the HIV antibody test; and steps to prevent the spread of HIV. Proper male and female condom use was demonstrated and rehearsed, and women received a risk-reduction and toiletry kit. Women were also taught violence prevention strategies such as staying sober to assess a situation, communication techniques to employ in difficult situations, and ways to exit a volatile situation if necessary.

The intervention involved two one-on-one sessions held within 2 weeks, each lasting approximately 1 hour. Sessions were conducted by trained interventionists in English, Zulu, or Sesotho, depending on the woman’s language preference. Women were also provided with active referrals to local service organizations for needs that required extensive counseling and other services.

Study

The Women’s Health CoOp was a randomized community trial of an adapted behavioral HIV prevention intervention for high-risk women in Pretoria, South Africa, who used alcohol and other drugs. The study was conducted by Wechsberg and colleagues (2011). Individuals were eligible for the study if they (a) were female; (b) were 18 years of age or older; (c) reported use of alcohol on at least 13 of the past 90 days; (d) were active sex workers (traded sex for money, drugs, clothing, shelter, or any other goods in the past 90 days) or reported having unprotected sex in the past 90 days; (e) lived in Gauteng Province and planned to live there for the next 6 months; and (f) reported South African citizenship. Women who met the preliminary eligibility requirements were referred to the project office to determine final eligibility.

Eligible women were randomized into one of two brief HIV prevention interventions: the woman-focused intervention or the standard intervention. Women randomized to the woman-focused intervention (described under Program Description) received two individual sessions held within 2 weeks, each lasting approximately 1 hour. Women randomized to the standard intervention received an adapted version of the revised National Institute on Drug Abuse (NIDA) standard intervention which consisted of two 1-hour educational and skill-building sessions held within 2 weeks. During each session, the individuals implementing the standard intervention used cue cards to provide information on HIV, drug and sex risks, risk-reduction methods, information on how to talk with a partner about safer sex practices, the HIV antibody test, and steps female participants should take to prevent the spread of HIV. Proper condom use was also demonstrated and rehearsed, and all participants received a risk-reduction and toiletry kit as well as information on referral sources. Only minor modifications were made to implement the NIDA standard intervention in South Africa, such as substance use terminology (e.g., marijuana is called “dagga” and crack cocaine is called “rock”).

Of the 801 individuals initially screened for eligibility, 583 were randomized to one of two intervention conditions. Of those randomized, 94 percent (550 women) returned for the 6-month follow-up and were included in the analyses. The woman-focused intervention consisted of 276 women and the NIDA standard intervention consisted of 274 women. About 41 percent of the women-focused intervention participants were between 18 and 24 years old; 44 percent were 25 to 34; and the remaining 15 percent were 35 or older. About half of the group (49 percent) were HIV positive; 64 percent were sex workers. In the NIDA standard intervention group, 38 percent were 18 to 24 years old; 44 percent were 25 to 34; and 18 percent were 35 or older. More than half of the group (55 percent) were HIV positive; 63.5 percent were sex workers. There were no significant differences between the groups in baseline demographic characteristics. There were also no significant differences between non-sex workers in the woman-focused intervention and the NIDA standard intervention group, and no significant differences between sex workers in each group.

The primary outcomes of interest were drug and alcohol use, sex risk, and violence. Outcomes were separated for sex workers and non-sex workers to control for baseline differences. Alcohol and other drug testing were conducted at intake and at the 6-month follow-up using the Medimpex Breathscan Alcohol Detector and the Multi-Drug Panel Drug Urine Test for immediate onsite testing. Women were tested for amphetamine, methamphetamine, cocaine, opiates, THC, and ecstasy in their urine. The results from the five-panel urine drug screen were collapsed into four categories: positive for any drug, positive for one drug, positive for two drugs, or positive for more than two drugs. The women were also asked a series of questions regarding their use of alcohol, tobacco, and several other drugs, including marijuana, ecstasy, crack cocaine, heroin, LSD, and inhalants. Women were asked how many days they had used substances in the past 30 days, how many days they had gotten drunk, how many drinks they consumed (on average) per day when drinking, and how many drinks they consumed on a typical drinking day. Sex risk for non-sex workers was assessed as use of a male or female condom during last sexual intercourse with a main partner. Sex risk for sex workers was assessed with two variables: whether the woman had used a male or female condom during last intercourse with her main partner and during last intercourse with a client. Finally, gender-based violence was assessed by asking women if they had experienced physical or sexual abuse by a client or main sex partner in the past 90 days. They were also asked how many times in the past 90 days they had experienced a range of violent acts by their main partners, clients, and others.

To evaluate the effectiveness of the intervention within each group over time (baseline to 6 months post-intake), the study used paired t-test for continuous data, McNemar's test for dichotomous data, and Wilcoxon signed-rank test for ordinal data. Comparative effectiveness of the interventions was assessed by examining the magnitude of the effect sizes (Cohen’s d). No subgroup analyses were conducted.

The woman-focused intervention was adapted from an intervention originally designed to address the needs of inner-city African American female crack cocaine users in the United States. The program was adapted to serve female sex workers and other vulnerable women in South Africa. A community advisory board (CAB) was established to provide technical guidance and support when necessary. The CAB consisted of representatives from government, nonprofit organizations, service providers, and researchers. In addition, the mayor’s office in Pretoria established a task force to locate housing and education services for sex workers, and the Department of Health provided free female and male condoms to distribute in communities.

A field manual was developed to address daily operations, including information on referrals for participants to available local resources. Full-time staff who spoke Afrikaans, English, Zulu, and Sesotho were trained to conduct outreach, collect urine samples and test for substance use, and deliver the two-session intervention. Intervention sessions were led by staff using cue cards in English, Zulu, or Sesotho, depending on the participant’s language preference (Wechsberg et al., 2006).

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Lyles, C.M., L.S. Kay, N. Crepaz, J.H. Herbst, W.F. Passin, A.S. Kim, S.M. Rama, S. Thadiparthi, J.B. DeLuca, and M.M. Mullins. 2007. “Best-Evidence Interventions: Findings From Systematic Review of HIV Behavioral Interventions for US Populations at High Risk, 2000–2004.” American Journal of Public Health 97(1):133–43.

Jones, Hendree E., Felicia A. Browne, Bronwyn J. Myers, Tara Carney, Rachel Middlesteadt Ellerson, Tracy L. Kline, Winona Poulton, William A. Zule, and Wendee M. Wechsberg. 2011. “Pregnant and Non-Pregnant Women in Cape Town, South Africa: Drug Use, Sexual Behavior, and the Need for Comprehensive Services.” International Journal of Pediatrics 2011, Article ID 353410.

Jones, Hendree E., Bronwyn Myers, Kevin E. O’Grady, Stefan Gebhardt, Gerhard B. Theron, and Wendee M. Wechsberg. 2014. “Initial Feasibility and Acceptability of a Comprehensive Intervention for Methamphetamine-Using Pregnant Women in South Africa.” Psychiatry Journal 2014, Article ID 929767.

Minnis, Alexandra, Irene A. Doherty, Tracy L. Kline, William A. Zule, Bronwyn Myers, Tara Carney, and Wendee M. Wechsberg. 2015. “Relationship Power, Communication, and Violence Among Couples: Results of a Cluster-Randomized HIV Prevention Study in a South African Township.” International Journal of Women’s Health, 517–25.

Wechsberg, Wendee M., Wendy K. Lam, William A. Zule, and G. Bobashev. 2004. “Efficacy of a Woman-Focused Intervention to Reduce HIV Risk and Increase Self-Sufficiency Among African American Crack Abusers.” American Journal of Public Health 94(7):1165–73.

Wechsberg, Wendee M., Winnie K. Luseno, and Wendy K. Lam. 2005. “Violence Against Substance-Abusing South African Sex Workers: Intersection with Culture and HIV Risk.” AIDS Care 17(Suppl. 1):S55–64.

Wechsberg, Wendee M., Winnie K. Luseno, Wendy K. Lam, Charles D. Parry, and Neo K. Morojele. 2006. “Substance use, Sexual Risk, and Violence: HIV Prevention Intervention With Sex Workers in Pretoria.” AIDS Behavior Journal 10(2):131–37.

Wechsberg, Wendee M., Winnie K. Luseno, K. Riehman, R. Karg, Felicia A. Browne, and Charles D. Parry. 2008. “Substance Use and Sexual Risk Within the Context of Gender Inequality in South Africa.” Substance Use and Misuse 43(8–9):1186–1201.

Wechsberg, Wendee M., Winnie K. Luseno, Tracy L. Kline, Felicia A. Browne, and William A. Zule. 2010. “Preliminary Findings of an Adapted Evidence-Based Woman-Focused HIV Intervention on Condom Use and Negotiation Among At-Risk Women in Pretoria, South Africa.” Journal of Prevention & Intervention in the Community 38(2):132–46.

Wechsberg, Wendee M., Rachel Jewkes, Scott P. Novak, Tracy Kline, Bronwyn Myers, Felicia A. Browne, Tara Carney, Antonio A. Morgan Lopez, and Charles Parry. 2013. “A Brief Intervention for Drug Use, Sexual Risk Behaviours and Violence Prevention with Vulnerable Women in South Africa: A Randomised Trial of the Women’s Health CoOp.” BMJ Open 3(5):e002622.

Wechsberg, Wendee, Jacqueline Ndirangu, Ilene Speizer, William Zule, Winnifred Gumula, Courtney Peasant, Felicia Browne, and Laura Dunlap. 2017. “An Implementation Science Protocol of the Women’s Health CoOp in Healthcare Settings in Cape Town, South Africa: A Stepped-Wedge Design.” BMC Women’s Health 17(1):85.

Wechsberg, Wendee, William Zule, Jacqueline Ndirangu, Tracy Kline, Nathaniel Rodman, Irene Doherty, Scott Novak, and Charles van der Horst. 2014. “The Biobehavioral Women’s Health CoOp in Pretoria, South Africa: Study Protocol for a Cluster-Randomized Design.” BMC Public Health 14(1):1074.

Zule, William, Bronwyn Myers, Tara Carney, Scott P. Novak, Kaitlin McCormick, and Wendee M. Wechsberg. 2014. “Alcohol and Drug Use Outcomes Among Vulnerable Women Living with HIV: Results from the Western Cape Women’s Health CoOp.” AIDS Care 26(12):1494–99.