wendee m. wechsberg july 22, 2012

SATELLITE SESSION: XIX Annual International AIDS Conference

RTI International is a trade name of Research Triangle Institute. 1

Strategies and Barriers to Scaling Up a Women's Empowerment Interventionin South Africa: Addressing Drugs, Sex and VictimizationWendee M. WechsbergJuly 22, 2012


Over 10 years of Intervention Studies with Women in South Africa

Thank you NIDA, NIAAA, NICHD RTI Staff MRC Staff Sizanang Wesley Community Centre Especially all the women in

these studies

TEAMWORK IS KEY TO SUCCESS2


Barriers/Challenges for Vulnerable Women who use Drugs & Drink Alcohol

Lack of confidence & personal power Relationships with men and peers Minimal education & skills Lack of knowledge and skills (Self-efficacy

using condoms/ lack of negotiation skills) Gender-based violence Co-morbidity (e.g., STIs), lack of health

access Resources limited locally Stigma from service providers


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Pretoria, South AfricaMay 29, 2012


Intersection of Culture and Context

Poor housing, high unemployment Devaluation of girls for education

attainment Classism, racism, and sexism

STIs, TB and other diseases because of poor nutrition

Sex work is often the only option for employment


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Unemployment Leads to Sex Work and Sex Work Leads to Drug Abuse

“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.”

Forty-four percent have been too high on drugs to negotiate condom use (Sunnyside sex worker study).


Intersection of Culture, Context, Gender & Violence Men drinking, men being

abusive and gender-based violence in general

Gender roles and cultural expectations

Sexual expectations and rape 40-50% of women in targeted

studies have been a victim of physical IPV

Over 40% of men have perpetrated violence against a female partner

Gender-based violence is the 2nd leading cause of death in the country, after HIV


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Adaptations of the Women’s CoOp: A Feminist/Empowerment Framework

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Original Women’s CoOp: Woman-Focused HIV PreventionKey concepts & components

Addressing drug dependence as a state of oppression

Supporting recovery and treatment referrals

Developing personal goals of protection & independence

Developing personal skills in making choices

Acting on goals and choices

Developing positive supports to maintain them

“Empowerment-based: Step-by-step”


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Adapting to South Africa’s Environment and Culture

Empowerment-based =Less alcohol & drug use = Greater power

Focused on Gender-based violence & Condom Use Mastery


Reaching and Testing Women for HIV

City, Sub-group % HIV+

PretoriaSex Workers

68%

Pretoria Non Sex workers

34%

Cape TownBlack African Women

38%

Cape Town Coloured Women

7%

Women’s Health CoOp Studies in South Africa

Modal Age = 23 years


Selected OutcomesSex workers were more likely to: Have past year diagnosis of alcohol or other drug abuse or dependence Need for drug treatment (tx) and desire to go for tx Tx unknown or tried but unable to enter Have been physically abused Evidence of denial of HIV status in a significant proportion of the sample A great unmet need may exist among those who are most in need of health

services because of poor access to services or delay in seeking medical care

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High levels of HIV, denial, access, AOD use, and abuse


Reduced Alcohol Use

7.6

7.7

7.8

7.9

8

8.1

8.2

8.3

Baseline 3MFU 6MFU

Aud

it Sc

ore

Woman-Focused Standard

Woman-Focused (n=290): Baseline – 3MFU (ns); Baseline – 6MFU (p<.05)Standard (n=293) : Baseline – 3MFU (p<.05); Baseline – 6MFU (ns)


Reduced Unprotected Sex with Main Sex Partners: Past 30 Days

01234567

Baseline 3MFU 6MFU

Mea

n Ep

isod

es


Woman-Focused (n=290): Baseline – 3MFU (p<.01); Baseline – 6MFU (p<.01)Standard (n=293): Baseline – 3MFU (p<.01); Baseline – 6MFU (ns)


Reduced Physical Victimization by Main Partner: Past 90 Days

0

5

10

15

20

25

Baseline 3MFU 6MFU

Perc

ent


Paired-sample t-testsWoman-Focused (n=290): Baseline – 3MFU (ns); Baseline – 6MFU (p<.05)Standard (n=293): Baseline – 3MFU (p<.01); Baseline – 6MFU (p<.01)


Does the intervention for vulnerable women work?

Less physical abuse by a main partner Fewer days of drinking Higher condom negotiation Higher condom use HIV+ women reported greater sexual control and HIV-

women demonstrated greater self-efficacy for sexual discussion and were more likely to use condoms

Thus, interventions targeting vulnerable women need to consider HIV risk posed in personal relationships with main partners who have multiple sex partners

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Research to Dissemination to Policy to Practice

Conducted a Policy Forum in South Africa

Disseminated a Policy Brief, newsletter and publications

Right to Care (PEPFAR NGO) took over clinic and staff

Started new NIH proposal for Combination biobehavioral Prevention for next generation science (reach, test, treat, retain)

Packaged the intervention for implementation, scalability and sustainability


Why Package the WHC Intervention?

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Listed in USAID’s “Multiple Gender Strategies to Improve HIV and AIDS Interventions: A compendium of Programs in Africa”

The WHC is for vulnerable women in South Africa that addresses alcohol and drug use, sexual risk, violence, and supports empowerment.


Strategies to Packaging the WHC Intervention

Talking to USAID, CDC PEPFAR, RTI

Proposal for funding Internal funding Pretesting/Review

Phase Pilot testing training Final round of edits Funding to Scale Up

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The Packaged Women’s Health CoOp

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Chapter 1: Packaged “Toolkit”: Trainer’s ManualChapter 2: Training InformationChapter 3: Intervention Cue Cards, Session 1 & 2Chapter 4: Intervention Fidelity and Quality AssuranceChapter 5: Appendices

Optional Chapter: The Role of Outreach


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Reaching Women Where They Work and Live

In the bush, truck stops, mines

Brothels, shelters


Barriers to Overcome when Reaching Vulnerable Women in South Africa

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• Daily survival (e.g. food, shelter)• Access to substance abuse treatment• Regular care for STI treatment• HIV medical monitoring and ARVs (clinics far away, out of

drugs, no transport $$)• Housing • Literacy programs• Micro-financing (empowerment coops)• Life skills training (how to be independent)• Specific skills training for targeted jobs (e.g. computer skills)


Partnership and Scale Up Expectations

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• Be clear about role and responsibilities• Conduct in-service with partners • Conduct trainings with stakeholders• Develop local strategy w/CABs of scale up• Utilize local health department capacity & local NGO linkages• Hire & train peers for outreach & the intervention• Establish resource and referral network• Establish local & reliable project materials (e.g. female

condoms)• Address funding shortages, PEPFAR priorities & changes,

health department limitations


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Strategies to Assist Staff

Staying positive, open-minded, flexible and supportive- role modeling Having regular staff debriefings and meetings Ongoing trainings and in-services Having staff not be too pushy but conduct case management Maintaining a secure and comfortable field site or mobile unit so women will

come to test and receive intervention Economize with donations from food banks, and innovate with transport Being up-to-date with government policies (e.g. testing regs., drug tx ctrs.)

Working with poor women who face limited economic opportunities, abuse substances, are at high risk for HIV/have HIV, and face regular physical and sexual abuse in their daily lives is difficult


The Most Important Key to Success


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References

Wechsberg, W. M., Luseno, W. K., Zule W. A., Kline, T. L., Browne, F. A., Novak, S. P., & Middlesteadt Ellerson, R. (2011). Effectiveness of an adapted evidence-based woman-focused intervention for sex workers and nonsex workers: The Women’s Health CoOp in South Africa. Journal of Drug Issues.

Luseno, W.K., Wechsberg, W.M., Kline, T.L., & Middlesteadt Ellerson, R. (2010). Health services utilization among South African women living with HIV and reporting sexual and substance-use risk behaviors. AIDS Patient Care and STDs, 24(4), 257–264.

Wechsberg, WM, Luseno, W.K., Kline, T.L., Browne, F.A., & Zule, W.A. (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 and Intervention in the Community, 38, 132–146.

Luseno, W.K., & Wechsberg, W.M. (2009). Correlates of HIV testing in a sample of high-risk South African women. AIDS Care, 21, 178–84.

Wechsberg, W.M., Wu, L., Zule, W.A., Parry, C.D., & Browne, F.A., Luseno, W.K., Kline, T., & Gentry, A. (2009). Substance abuse, treatment needs and access among female sex workers and non-sex workers in Pretoria, South Africa. Substance Abuse Treatment, Prevention, and Policy, 4, 11.

Wechsberg, W.M., Luseno, W.K., Lam, W.K., Parry, C.D., & Morojele, N.K. (2006). Substance use, sexual risk, and violence: HIV prevention intervention with sex workers in Pretoria. AIDS and Behavior, 10(2), 131–137.


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Reaching Vulnerable Women has to be at the Forefront of the HIV Global Agenda

Women are more vulnerable and lack power.

The Women’s Health CoOp is an empowerment-based program that could reach South Africa’s most vulnerable women as it is scaled up.

For more information:www.rti.org/[email protected]

wendee m. wechsberg july 22, 2012

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