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.
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).
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.
18 to 100
Overall, Wechsberg and colleagues (2011) found mixed results when examining the effectiveness of the Women’s Health CoOp women-focused intervention compared to the National Institute on Drug Abuse (NIDA) standard intervention. Outcomes were separated for sex workers and non-sex workers to control for baseline differences.
Non-sex workers in both interventions showed improvements in outcome measures. At the 6-month follow-up, non-sex workers in the woman-focused intervention self-reported significantly fewer days of drinking in the past 30 days compared to non-sex workers in the NIDA standard intervention (4.6 days versus 6.4 days, respectively). Non-sex workers in the woman-focused intervention were also significantly more likely to report using a condom during last sexual intercourse with a main partner (52 percent versus 31 percent) and less likely to report sexual abuse by a main sex partner (4.6 percent versus 11.2 percent). However, there were no significant differences in all other measures at the 6-month follow-up, including self-reported and biochemically verified drug use and physical abuse by a main sex partner.
Over time (from baseline to 6 months), non-sex workers in the NIDA standard intervention reported significantly greater reductions in drug use and physical abuse by a main sex partner in the previous 90 days than those in the woman-focused intervention. However, non-sex workers in the woman-focused intervention reported significantly greater reduction in sexual abuse by a main sex partner. There were no other significant differences between the groups in any other measures over time.
Similarly to the non-sex workers, sex workers in both the woman-focused intervention and NIDA standard intervention groups demonstrated statistically significant improvements over time in most of the outcomes of interest. At the 6-month follow-up, there were no significant differences between the groups in any of the measures, except for physical abuse by a main sex partner (3.9 percent of sex workers in the woman-focused intervention reported incidences of physical abuse compared to 11.2 percent of the NIDA standard intervention).
However, over time (from baseline to 6 months) sex workers in the woman-focused intervention had significantly better outcomes than sex workers in the NIDA standard intervention in biochemically verified drug use, condom use during last intercourse with a main partner, and physical abuse by their clients in the previous 90 days. There were no other significant differences between the groups in any other measures over time, including sexual abuse by clients in the previous 90 days and sexual and physical abuse by a main sex partner.