July 9, 2007
Studies of HIV prevention interventions from remote villages in South Africa and from the ‘gay ghetto’ of Miami, presented at the Eighth AIDS Impact Conference in Marseilles last week, show that facilitating dialogue between potential transmitters and acquirers of HIV who normally don’t talk together – in one case young men and women, in the other HIV-positive and negative gay men – can produce significant reductions in risk behaviour and in HIV/STI incidence.
South Africa: The Stepping Stones Study
Stepping Stones is not a new programme. Devised in 1995 by Alice Welbourn, Chair of the International Community of Women Living with HIV (ICW), it is described as a “gender transformative programme for HIV intervention,” in other words it uses participatory learning groups to bring young women and men together to talk about issues such as sexual violence, women’s inequality, negotiating condom use and the way gossip is used to destroy reputation.
Introduced in Uganda, it was brought to South Africa in 1998, but this trial was the first proper evaluation of its biological and behavioural outcomes. Direct measurements of HIV and STI incidence are quite rare in studies of behavioural interventions, as they require large study groups in high-incidence areas. Most studies measure behavioural outcomes.
Rachel Jewkes of the South African Medical Research Council told the conference that Stepping Stones was probably the most widely-used HIV behavioural intervention in the world. Other countries that have used it include Tanzania and Mozambique, where 500,000 young people have been through the programme.
The intervention consists of 14 three-hour single-sex groups for young women and men, who are then brought together for three mixed-sex dialogue groups. This controlled trial consisted of comparing the full Stepping Stones programme with one called “Stepping Stones Short” which included the modules on HIV information, safer sex and condom use but omitted the broader discussions of gender relations.
The trial recruited 1423 women and 1371 men aged 15-26 years from 70 villages in a remote rural region of Eastern Cape province around the town of Umtata. Villages, rather than individual participants, were randomised to receive either the full or the short programme.
Most of the young people were recruited through schools. HIV and herpes (HSV-2) prevalence and sexual behaviour were assessed at baseline, 12 months and 24 months through blood tests and in a face to face interview. Follow-up rates at 24 months were 87% (for blood tests) and 75% (for the behavioural re-interview). All 70 villages stayed in the programme.
A small qualitative study interviewing 11 women and 10 men before and after the study elicited more in-depth reactions to the programme.
At baseline 11% of the women and 2% of the men had HIV, and 27% and 10% respectively had HSV-2. Incidence of HSV-2 was measured because HSV-2 infection increases vulenrability to HIV infection due to genital herpes ulcers, and because HSV-2 infection, even without symptomatic genital herpes, may increase HIV shedding in genital fluids, particularly in women.
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At follow-up there was no difference in HIV incidence amongst the men (1.38% a year in both arms) and only a non-significant difference in herpes incidence (1.42% versus 2.02%, p = 0.36), though Jewkes commented that HIV incidence was generally lower than expected. In women there was a non-significant difference in HIV incidence (5.69% versus 6.74%, p = 0.35), but a significant difference in herpes acquisition (5.1% versus 7.4%). Adding together HIV and HSV-2 incidence in both women and men yielded a ‘composite efficacy’ of 31% for the programme.
There were significant behavioural changes amongst the men. Men in the full programme reported 9% fewer sexual partners at 12 months and 14% fewer at 24 months and also reported more condom use, less transactional sex, less severe inter-partner violence, and less substance use. Forty-four per cent of men in the intervention arm decided to get an HIV test versus 34% in the control arm.
There were fewer differences in behavioural outcomes for women, which may reflect less ability to take control over behaviour. Jewkes told the conference that young men showed increased rates of carrying condoms (even though one man described doing this as “hunting with salt”, i.e. appearing over-ready for sex) and using them.
Women however showed less sense of agency in their dealings with men; one young woman described her experience of unsafe sex with an older boyfriend (a teacher) as “these things happen on their own,” and although some women were able to insist on condom use, others described not daring to for fear of jeopardising their relationship.
Miami: the MensROOM Study
The intervention in Miami, in contrast to Stepping Stones, was a pilot intervention of a new concept in HIV prevention for gay men in which ‘high-risk’ HIV positive and HIV negative gay men were brought together to discuss HIV risk and risk behaviour.
Researcher Steven Kurtz of the University of Delaware first conducted extensive focus groups among gay men described as heavy substance users (meaning more than three instances of recreational drug use in the last 90 days, excluding alcohol) and having significant amounts of unprotected sex (meaning more than two incident in the last 90 days).
This fieldwork indicated that HIV risk was exacerbated, said Kurtz, “because of striking differences in HIV-positive and HIV-negative men’s attitudes toward the severity and meaning of HIV infection, their perceptions of responsibility for self protection and disclosure, and the lack of shared meanings of non-verbal serostatus disclosure techniques.”
He told the conference: “Safer sex behaviour and serostatus disclosure norms are different for HIV positive and negative men.”
Because of this, he came to the conclusion that conducting discussion or support groups restricted to men of one HIV status may do more harm than good.
“Serostatus-segregated risk reduction interventions maintain social segregation,” he told the conference, “and may sustain bounded disclosure norms.”
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