The overall objective is to determine the effectiveness of a behavioral intervention, Stepping Stones, in reducing the transmission of HIV and promoting HIV risk reducing practices, among poor rural women and men in South Africa. The study seeks to determine the effectiveness of Stepping Stones, in changing aspects of gender dynamics in relationships, including violent practices, and measure the impact of this on HIV risk reduction. It also aims to determine the magnitude of risk of HIV attributable to sexual practices, other than condom use, unequal gender power in relationships and violence. The Stepping Stones intervention is a workshop series of 14 sessions which cover HIV, sexual and reproductive health, gender, communication and relationship skills. It was developed in Uganda and has been specifically adapted and used in many developing countries. The South African adaptation was made in 1998 and it has since been used widely in the country. The study design is a duster randomized controlled trial with randomization to receive Stepping Stones immediately or in two years. The setting is the rural Eastern Cape Province of South Africa. Study subjects are 1400 men and 1400 women of 16-30 years. There will be 70 clusters, with each having one group of 20 women and one of 20 men. Clusters will be randomized. The primary outcome measure will be the proportion of subjects HIV sero-converting between baseline and two years, by gender. The secondary outcomes include changes in knowledge, attitude and practices related to HIV, condom use, number of partners, gender relations and gender violence. Measurement will use Determine (Abbott Laboratories) rapid HIV tests and a standard questionnaire. Ethnographic research will be undertaken to inform the questionnaire design and interpretation of study findings. It will explore the relationships between gendered identities and sexual and violence practices. It will also seek to understand what are the barriers to behavior change and what strategies are used by which people to circumnavigate these.
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