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Strategies and Barriers to Scaling Up a Women's Empowerment Intervention in South Africa: Addressing Drugs, Sex and Victimization. Wendee M. Wechsberg July 22, 2012. Over 10 years of Intervention Studies with Women in South Africa. Thank you NIDA, NIAAA, NICHD RTI Staff MRC Staff Sizanang

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Wendee M. Wechsberg July 22, 2012

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Strategies and Barriers to Scaling Up a Women's Empowerment Interventionin South Africa: Addressing Drugs, Sex and Victimization

Wendee M. Wechsberg

July 22, 2012

RTI International is a trade name of Research Triangle Institute.

over 10 years of intervention studies with women in south africa
Over 10 years of Intervention Studies with Women in South Africa

Thank you

  • RTI Staff
  • MRC Staff
  • Sizanang
  • Wesley Community Centre
  • Especially all the women in these studies


barriers challenges for vulnerable women who use drugs drink alcohol
Barriers/Challenges for Vulnerable Women who use Drugs & Drink Alcohol
  • Lack of confidence & personal power
  • Relationshipswith 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
intersection of culture and context
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
unemployment leads to sex work and sex work leads to drug abuse
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
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

original women s coop woman focused hiv prevention key concepts components
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”

adapting to south africa s environment and culture
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

Modal Age = 23 years

Women’s Health CoOp Studies in South Africa

selected outcomes
Selected Outcomes

Sex 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

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

reduced alcohol use
Reduced Alcohol Use

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
Reduced Unprotected Sex with Main Sex Partners: Past 30 Days

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
Reduced Physical Victimization by Main Partner: Past 90 Days

Paired-sample t-tests

Woman-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
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

research to dissemination to policy to practice
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
Why Package the WHC Intervention?

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
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
the packaged women s health coop
The Packaged Women’s Health CoOp

Chapter 1: Packaged “Toolkit”: Trainer’s ManualChapter 2: Training InformationChapter 3: Intervention Cue Cards, Session 1 & 2

Chapter 4: Intervention Fidelity and Quality AssuranceChapter 5: AppendicesOptional Chapter: The Role of Outreach

reaching women where they work and live
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
Barriers to Overcome when Reaching Vulnerable Women in South Africa
  • 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
Partnership and Scale Up Expectations
  • 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
strategies to assist staff
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 txctrs.)

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

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.

reaching vulnerable women has to be at the forefront of the hiv global agenda
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: