Results from a 2005 antenatal survey conducted in all nine South African provinces indicate that the Western Cape Province had the highest rate of increase of HIV infection among all provinces: from 13.1% in 2003 to 15.7% in 2005. Among Black African and Coloured women, noninjecting drug use is associated with high-risk sexual behavior, HIV seropositivity, and sexually transmitted infections (STIs). In addition, violence against women is widespread in South Africa, which further exacerbates their HIV risks. A recent pilot study conducted in the Western Cape townships explored an evidence-based woman-focused intervention to reduce drug use, sexual risk, and victimization by addressing the intersection of these factors among poor, substance-using women. The pilot study explored the feasibility and promise of the woman-focused intervention in both an individual and group-based format through a small randomized trial. Both Black African and Coloured women reported high levels of substance abuse, as well as high levels of sexual risk behavior (e.g., multiple partners and unprotected sex) and victimization. Findings from the pilot study suggest that women reduced substance use (with biological verification), sexual risk behavior, and victimization. The group intervention, however, created an ongoing effect in the community in which women who participated in the two group sessions continued to meet after the study ended to provide support for one another and reinforce positive changes. The group format complemented the strong sense of community cohesion intrinsic to the Western Cape townships. The proposed revised study builds on this pilot study and is designed to reach a larger sample of women via a full-scale effectiveness study by adding a woman-focused intervention after voluntary counseling and testing (VCT). This multi-method research will conduct an extensive evaluation using qualitative and quantitative methods, repeated measures, and biological testing to determine the effectiveness of the woman-focused intervention to increase knowledge and skills to reduce substance abuse, sexual risk behaviors, and victimization. Former pilot study participants indigenous to the target communities will be trained as outreach workers to screen, recruit, and track 900 female study participants. The primary aim of the study is:
Aim 1. To test the effectiveness, through a randomized controlled trial, of VCT plus a woman-focused intervention relative to VCT only to increase knowledge and skills to reduce substance abuse, sexual risk, and victimization, and to an equal-attention (nutrition) control group at 3-, 6-, 9-, and 12-month follow-ups. The secondary aim of the study is as follows:
Aim 2. To examine the moderating effect of victimization (i.e., sexual and physical) and the mediating effects of HIV risk knowledge, condom use skills, sexual negotiation assertiveness, and relationship power on the effectiveness of the woman-focused groups to decrease risk related to drug use, sexual risk, and sex-related- victimization relative to the rapid testing group and to the equal-attention control group.
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