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close this bookEffective Approaches for the Prevention of HIV/Aids in Woman (PAHO, WHO; 1995; 62 pages)
View the documentExecutive summary
View the document1. Introduction
View the document2. Opening of the meeting
Open this folder and view contents3. Women and HIV/AIDS
close this folder4. Effective approaches to prevention of HIV/AIDS in women
close this folder4.1 Promoting safer sexual behaviour
View the documentAIDS prevention for women: a community-based approach in Botswana
View the documentEducational interventions for AIDS prevention among single migratory female factory workers in Thailand
View the documentWomen Helping to Empower and Enhance Lives: a prevention programme for hard-to-reach women in the USA, Mexico and Puerto Rico
View the documentReproductive health education and services for adolescents in Mexico
View the documentEffective approaches to HIV/AIDS prevention in women through the promotion of safer sexual behaviour - Conclusions
Open this folder and view contents4.2 Prevention of HIV/AIDS/STD through STD care and condom promotion
Open this folder and view contents5. Experiences from other fields: implications for HIV/AIDS prevention
Open this folder and view contents6. Future directions: national policies and large-scale programmes
View the document7. Overall conclusions
View the documentAppendix 1 - Agenda
View the documentAppendix 2 - List of participants
View the documentAppendix 3 - List of background papers
View the documentAppendix 4 - Selected reading list

Women Helping to Empower and Enhance Lives: a prevention programme for hard-to-reach women in the USA, Mexico and Puerto Rico

Presented by Dr Rebecca Ashery, National Institute on Drug Abuse, National Institutes of Health, Maryland, USA.

In 1989, fewer than 2000 American women who were diagnosed with AIDS were sexual partners of injecting drug users (IDUs). As of June 1994, over 50 000 American women have been diagnosed with AIDS and of them, 10 000 contracted the HIV virus by having sex with an IDU. The increasing proportion of women becoming infected by IDUs is to be expected according to findings from a study of 12 000 male IDUs. More than 40% reported having sex with at least three non-injecting women during the 6 months prior to their baseline interview and only 10% reported that they always used a condom, suggesting that 20 000 women may have been placed at risk in this manner. Unfortunately, in many parts of the world, HIV transmission through injecting drug use is on the rise - putting many more women at risk.

The “Women Helping to Empower and Enhance Lives” (WHEEL) project was initiated in order to learn more about ways to reach this high-risk population of sexual partners of IDUs. Its goal was to evaluate and compare two interventions to reduce HIV-related sexual risk behaviours and HIV-related drug risk behaviours among partners of IDU’s.

The five-centre study was conducted in three sites in the USA (Boston, Massachusetts; Los Angeles and San Diego, California), in Juarez, Mexico, and in San Juan, Puerto Rico. These sites were chosen to represent social and cultural diversity, and because there were no existing HIV prevention programmes in the sites. Training and technical assistance were provided to the outreach workers, nurses, social workers, crisis counsellors, drug-abuse treatment counsellors, and others working with the 2794 study participants.

To be eligible for participation as a female sexual partner of an IDU, women had to meet the following criteria: they must have had sexual intercourse with an IDU at least once in the 5 years prior to the baseline interview; the woman’s partner must have injected drugs at least once in the 5 years prior to the baseline interview; and women should not have injected any drugs in the year prior to their baseline interview. Participants were recruited by outreach workers who made contacts in homes, churches, laundromats and other places. Follow-up took place 6 months after the baseline data collection.

The two interventions being tested were an intervention (with four components) for individuals, and the same individual intervention with the addition of three group sessions. The components common to both interventions consisted of a general health needs assessment, HIV-related education and risk assessment, HIV pre-test counselling, and post-test counselling for women who opted to have the test. Whenever possible, attempts were made to meet needs identified during sessions (e.g. food, clothing, service referrals).

In the second intervention, women participated in three additional, weekly group sessions led by trained facilitators. Two of these 2-hour sessions were based on modules chosen by the group itself. The seven modules from which the women selected (initially chosen as topics as a result of focus group discussions) were sexuality, health, addiction, keeping safe from domestic violence, relationships, survival and parenting. In the third session, women learned to “teach-back” to others specific portions of the modules in which they had participated. Successful completion of the group intervention was rewarded with a graduation ceremony during which certificates of completion and peer education packets were issued.

The findings, described below, clearly showed that both interventions were successful in reducing drug use and high risk sexual behaviours at the 6-month follow-up. There were no significant differences between the effectiveness of the two interventions in any of the sites (data from both interventions were subsequently pooled). This latter finding may not mean that no differences actually exist but may be the result of a biased loss to follow-up: the follow-up rate for women in the group intervention was only 58% (as compared to 70% of all participants), the majority did not complete all three group sessions, and those from the group intervention lost to follow-up were, according to a composite point scale, at particularly high risk.

These figures signal the need for greater efforts and more innovative approaches for this diverse population of women. The reported changes in high risk sexual behaviour of participants who were followed up were substantial and occurred at all levels of risk (low, medium, high). For example, the number of women who had sex with IDUs in the previous month declined by 46.7% between baseline and follow-up (Figure 4). The frequency of engaging in unprotected vaginal sex decreased by 15.7%.

Figure 4

Decreases in risk behaviours of female partners of injecting drug users in intervention sites in the USA, Mexico and Puerto Rico


Lessons learned

• It is feasible to find, recruit and successfully intervene with female sexual partners of IDUs to reduce HIV transmission risks.

• In this vulnerable population, HIV prevention programmes can significantly increase participants’ self-esteem and awareness regarding issues of being controlled by one’s partner, and about HIV/AIDS.

• Despite its many successes, the project failed to retain the women most at risk and future efforts should include immediate follow-up when there is a “no show”, adaption of modules as necessary to different populations of female sex partners of IDU’s, and avoidance of placing women at high risk and women at low risk in the same group.

• Initial investment in the project was high, but could now be replicated at a much lower cost by adapting the field-tested, easy-to-use training modules that were developed.

• HIV prevention activities for women should be undertaken in women-friendly, woman-centred places and ideally should provide incentives in cash or kind such as transport, child care and other services valued by participants.

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