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