Download - Wendee M. Wechsberg July 22, 2012
SATELLITE SESSION: XIX Annual International AIDS Conference
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Strategies and Barriers to Scaling Up a Women's Empowerment Interventionin South Africa: Addressing Drugs, Sex and VictimizationWendee M. WechsbergJuly 22, 2012
SATELLITE SESSION: XIX Annual International AIDS Conference
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
SATELLITE SESSION: XIX Annual International AIDS Conference
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
SATELLITE SESSION: XIX Annual International AIDS Conference
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Pretoria, South AfricaMay 29, 2012
SATELLITE SESSION: XIX Annual International AIDS Conference
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
SATELLITE SESSION: XIX Annual International AIDS Conference
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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).
SATELLITE SESSION: XIX Annual International AIDS Conference
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
SATELLITE SESSION: XIX Annual International AIDS Conference
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SATELLITE SESSION: XIX Annual International AIDS Conference
Adaptations of the Women’s CoOp: A Feminist/Empowerment Framework
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SATELLITE SESSION: XIX Annual International AIDS Conference
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”
SATELLITE SESSION: XIX Annual International AIDS Conference
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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
SATELLITE SESSION: XIX Annual International AIDS Conference
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
SATELLITE SESSION: XIX Annual International AIDS Conference
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
SATELLITE SESSION: XIX Annual International AIDS Conference
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)
SATELLITE SESSION: XIX Annual International AIDS Conference
Reduced Unprotected Sex with Main Sex Partners: Past 30 Days
01234567
Baseline 3MFU 6MFU
Mea
n Ep
isod
es
Woman-Focused Standard
Woman-Focused (n=290): Baseline – 3MFU (p<.01); Baseline – 6MFU (p<.01)Standard (n=293): Baseline – 3MFU (p<.01); Baseline – 6MFU (ns)
SATELLITE SESSION: XIX Annual International AIDS Conference
Reduced Physical Victimization by Main Partner: Past 90 Days
0
5
10
15
20
25
Baseline 3MFU 6MFU
Perc
ent
Woman-Focused Standard
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)
SATELLITE SESSION: XIX Annual International AIDS Conference
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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SATELLITE SESSION: XIX Annual International AIDS Conference
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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
SATELLITE SESSION: XIX Annual International AIDS Conference
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.
SATELLITE SESSION: XIX Annual International AIDS Conference
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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SATELLITE SESSION: XIX Annual International AIDS Conference
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
SATELLITE SESSION: XIX Annual International AIDS Conference
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)
SATELLITE SESSION: XIX Annual International AIDS Conference
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
SATELLITE SESSION: XIX Annual International AIDS Conference
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]