An implementation science protocol of the Women’s Health CoOp in healthcare settings in Cape Town, South Africa: A stepped-wedge design

Abstract Background HIV persists as a public health emergency in South Africa, especially among women of childbearing age. In response to the HIV epidemic, the Joint United Nations Programme on HIV/AIDS has put forth the 90–90-90 global goals to achieve an AIDS-free generation by 2020. This goal aspires to have 90% of people living with HIV diagnosed; 90% of those who test positive on sustained antiretroviral therapy (ART); and 90% of those on ART be virally suppressed. Ensuring access to ART is an important first step in reducing HIV incidence, especially among vulnerable populations such as women who use substances and bear the burden of HIV in South Africa. Additionally, alcohol and other drug (AOD) use and exposure to gender-based violence are associated with increased risk of HIV infection and reduced adherence to ART. However, no research has estimated ART adherence rates for women who use substances in South Africa since the government approved the provision of ART to all people living with HIV. Methods The Women’s Health CoOp (WHC) is an evidence-based, woman-focused, behavioral intervention that addresses the intersecting risks of AODs, sex behaviors, and violence and victimization, with the primary goal of increasing skills and knowledge to reduce substance abuse and HIV risks and to improve ART adherence. The WHC has been packaged for further dissemination. This article describes the study protocol used to assess the feasibility and acceptability of implementing the WHC intervention into standard of care in Cape Town health clinics and substance abuse rehabilitation centers to reduce HIV risk behavior and increase ART adherence among women who use substances and are living with HIV. Discussion Because few of the interventions that demonstrate efficacy for HIV prevention and ART adherence in randomized trials are sustainable, studies to adapt and test intervention variations are needed to determine the best strategies for implementing them in real-world, high-risk settings. However, implementation in real-world settings presents challenges. Consequently, intervention developers should consider the strengths and limitations of their anticipated implementation setting by engaging with key stakeholders before, during, and after the adaptation and implementation process when developing and attempting to scale-up interventions. Trial registration NCT 02733003 and date approved 1/21/2016

Stigma in the health clinic and implications for PrEP access and use by adolescent girls and young women : conflicting perspectives in South Africa

DATA AVAILABILITY : Data and materials are available on request from Dr. Wendee Wechsberg at [email protected] : Globally, an urgent need exists to expand access to HIV prevention among adolescent girls and young women (AGYW), but the need is particularly acute in sub-Saharan Africa. Oral pre-exposure prophylaxis (PrEP) offers an effective HIV prevention method. In many countries, however, accessing PrEP necessitates that AGYW visit their local health clinic, where they may face access challenges. Some countries have implemented youth-friendly services to reduce certain challenges in local health clinics, but barriers to access persist, including clinic stigma. However, evidence of clinic stigma toward AGYW, particularly with respect to PrEP service delivery, is still limited. This mixed methods study explores stigma toward AGYW seeking clinic services, in particular PrEP, from the perspective of both clinic staff (clinical and nonclinical) and AGYW who seek services at clinic sites in Tshwane province, South Africa. METHODS : Six focus group discussions were conducted with AGYW (43 total participants) and four with clinic staff (42 total participants) and triangulated with survey data with AGYW (n = 449) and clinic staff (n = 130). Thematic analysis was applied to the qualitative data and descriptive statistics were conducted with the survey data. RESULTS : Four common themes emerged across the qualitative and quantitative data and with both AGYW and clinic staff, although with varying degrees of resonance between these two groups. These themes included (1) clinic manifestations of stigma toward AGYW, (2) concerns about providing PrEP services for AGYW, (3) healthcare providers’ identity as mothers, and (4) privacy and breaches of confidentiality. An additional theme identified mainly in the AGYW data pertained to stigma and access to healthcare. CONCLUSION : Evidence is needed to inform strategies for addressing clinic stigma toward AGYW, with the goal of removing barriers to PrEP services for this group. While awareness has increased and progress has been achieved around the provision of comprehensive, youth-friendly sexual and reproductive health services, these programs need to be adapted for the specific concerns of young people seeking PrEP services. Our findings point to the four key areas noted above where programs seeking to address stigma toward AGYW in clinics can tailor their programming.The Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health.http://www.biomedcentral.com/bmcpublichealtham2023Medical Microbiolog

Influence of Transformational Leadership on Employee Performance: A Case Study of Local Non-Governmental Organizations in Kenya

A Research Project Report Submitted to the Chandaria School of Business in Partial Fulfilment of the Requirement for the Degree of Master of Science in Organizational Development (MOD)This study sought to determine the influence of transformational leadership on employee performance, the study focused on local Non-Governmental Organizations (NGOs) in Kenya. The study was directed by specific objectives that sought to determine: the influence of idealized influence on employee performance, the influence of inspirational motivation on employee performance, the influence of intellectual stimulation on employee performance, and the influence of individualized consideration on employee performance. To achieve this, the study adopted a quasi-experimental research design known as correlational research design. This design was deemed appropriate for the study because it enabled the researcher to measure the independent variable (transformational leadership) and the dependent variable (employee performance). The population of the study comprised a total of 79 employees from the five local NGOs. The sample frame for the study was the official list of employees as obtained from the head of each organization. Purposive sampling technique was used to select the targeted respondents from each organization. The researcher targeted at least 60% of respondents from each organization to give a sample size of 49 respondents. The study showed that the organizations utilized available resources efficiently and employees were provided with feedback on their performance. The organizations set goals to define what they needed to achieve, and take into consideration available employee competencies to enable achievement of these goals. The study revealed that the organizations supported innovative efforts from employees and embraced two-way communication. The leaders in these organizations provided followers with an inspiring mission and vision, and they involved employees in achieving it. Leaders in these organizations encouraged employees to become part of the overall organizational culture, and acted as role models towards attainment of organizational goals. The study found that leaders in these organizations permitted employees to "think outside the box", and encouraged them to try new ways of looking at a problem. The leaders also took into consideration the sentiments of employees - even if they did not conform to the views held by the leaders themselves. The leaders celebrated each employee’s contribution to the team, were sensitive to specific knowledge and capabilities that employees had when assigning them tasks, and were timely in resolving conflict. The study concludes that leaders in these organizations influence employee performance by applying the transformational leadership style. The leaders provide an inspiring vision, support innovation and match employee competencies with organization goals and objectives. The leaders act as role models towards attainment of organizational goals and encourage employees to “think outside the box”. The leaders eliminate chances of conflict by making employees feel they are part of the solution and ensure timely resolution of conflict when it occurs. The study recommends that the leaders of the local NGOs should continuously inspire their employees to enhance their performance and enable the organization achieve its goals and objectives. During times when organizations are going through organizational change, leaders should purpose to adopt a transformational leadership style to ensure that employee performance is not affected and employees stay motivated

Social Determinants of Alcohol and Other Drug Misuse Among Women Living with HIV in Economically Underserved Communities in Cape Town, South Africa: A Cross-Sectional Study

This study aimed to understand how social determinants-the economic and social factors that affect health and well-being-are associated with self-reported and biological alcohol and other drug misuse in South Africa among women living with HIV. Logistic regression analyses were performed using baseline data from an implementation science trial conducted from 2015 to 2018 with 480 Black and Coloured women who were living with HIV and reported recent alcohol or other drug misuse. Educational attainment, type of housing, access to running water, food insecurity, and housing instability were examined. Women with higher education had reduced odds of any drug misuse-both biological (aOR: 0.53; 95% CI: 0.33-0.84) and self-reported (aOR: 0.37; 95% CI: 0.22-0.64). Women living in formal housing had increased odds of a positive alcohol screening test (aOR: 1.92; 95% CI: 1.16-3.18) and women with housing instability had increased odds of self-reported alcohol misuse-daily (aOR: 1.99; 95% CI: 1.18-3.35) and weekly (aOR:1.91; 95% CI: 1.19-3.07). Food insecurity was associated with reduced odds of self-reported alcohol misuse (aOR: 0.40; 95% CI: 0.25-0.64) and increased odds of self-reported drug misuse (aOR: 2.05; 95% CI: 1.16-3.61). These findings indicate the complexity of the relationship between social determinants and alcohol and other drug misuse, and may have implications for addressing social and structural determinants as part of multilevel interventions focused on reducing alcohol and other drug misuse among key populations of women in South Africa

The Young Women's Health CoOp in Cape Town, South Africa: Study protocol for a cluster-randomised trial for adolescent women at risk for HIV

Background: South Africa remains the global epicentre of HIV infection, and adolescent women have the highest incidence of HIV in the country. South Africa also has high rates of alcohol and other drug (AOD) use, violence, and gender inequality. Violence converges with AOD use, gender inequities and other disparities, such as poverty, to increase sexual risk and poor educational attainment for adolescent women. This study seeks to test the efficacy of peer recruitment and cofacilitation of the Young Women's Health CoOp (YWHC), a comprehensive gender-focused intervention to reduce HIV risk behaviours and increase the uptake of HIV counselling and testing (HCT) among out-of-school, adolescent women who use AODs. The YWHC is facilitated by local research staff and supported by peers. Methods: This cluster-randomised trial is enrolling participants into two arms: a control arm that receives standard HCT, and an intervention arm that receives the YWHC. Participants are enrolled from 24 economically disadvantaged communities in Cape Town, South Africa. These geographically distinct communities serve as clusters that are the units of randomisation. This study uses adolescent peer role models and research field staff to recruit marginalised adolescent women. At baseline, participants complete a questionnaire and biological testing for HIV, recent AOD use, and pregnancy. The core intervention is delivered in the month following enrollment, with linkages to health services and educational programmes available to participants throughout the follow-up period. Follow-up interviews and biological testing are conducted at 6 and 12 months post enrollment. Discussion: The study findings will increase knowledge of the efficacy of a comprehensive HCT, gender-focused programme in reducing AOD use, victimisation, and sexual risk behaviour and increase uptake services for out-of-school, adolescent women who use AODs. The trial results could lead to wider implementation of the YWHC for vulnerable adolescent women, a key population often neglected in health services. Trial registration: Trial registration no: NCT02974998, November 29, 2016

An implementation science protocol of the Women’s Health CoOp in healthcare settings in Cape Town, South Africa: A stepped-wedge design

Abstract Background HIV persists as a public health emergency in South Africa, especially among women of childbearing age. In response to the HIV epidemic, the Joint United Nations Programme on HIV/AIDS has put forth the 90–90-90 global goals to achieve an AIDS-free generation by 2020. This goal aspires to have 90% of people living with HIV diagnosed; 90% of those who test positive on sustained antiretroviral therapy (ART); and 90% of those on ART be virally suppressed. Ensuring access to ART is an important first step in reducing HIV incidence, especially among vulnerable populations such as women who use substances and bear the burden of HIV in South Africa. Additionally, alcohol and other drug (AOD) use and exposure to gender-based violence are associated with increased risk of HIV infection and reduced adherence to ART. However, no research has estimated ART adherence rates for women who use substances in South Africa since the government approved the provision of ART to all people living with HIV. Methods The Women’s Health CoOp (WHC) is an evidence-based, woman-focused, behavioral intervention that addresses the intersecting risks of AODs, sex behaviors, and violence and victimization, with the primary goal of increasing skills and knowledge to reduce substance abuse and HIV risks and to improve ART adherence. The WHC has been packaged for further dissemination. This article describes the study protocol used to assess the feasibility and acceptability of implementing the WHC intervention into standard of care in Cape Town health clinics and substance abuse rehabilitation centers to reduce HIV risk behavior and increase ART adherence among women who use substances and are living with HIV. Discussion Because few of the interventions that demonstrate efficacy for HIV prevention and ART adherence in randomized trials are sustainable, studies to adapt and test intervention variations are needed to determine the best strategies for implementing them in real-world, high-risk settings. However, implementation in real-world settings presents challenges. Consequently, intervention developers should consider the strengths and limitations of their anticipated implementation setting by engaging with key stakeholders before, during, and after the adaptation and implementation process when developing and attempting to scale-up interventions. Trial registration NCT 02733003 and date approved 1/21/2016

The PrEPARE Pretoria Project: protocol for a cluster-randomized factorial-design trial to prevent HIV with PrEP among adolescent girls and young women in Tshwane, South Africa

Background: Despite increased prevention efforts, HIV remains the leading cause of death among adolescent girls and young women in South Africa. Although research indicates important determinants of HIV acquisition at the individual and interpersonal levels, structural-level stigma and discrimination continue to be critical barriers to reaching and retaining this key population for HIV prevention and sexual and reproductive health services. Innovative and multilevel interventions are needed that can address the intersectional structural and gender issues that young women face, including stigma, alcohol and drug use, gender-based violence, and other risk factors when seeking health services. Oral pre-exposure prophylaxis (PrEP) taken daily has been found to be an effective biomedical HIV prevention tool. Testing a comprehensive gender-focused biobehavioral HIV prevention intervention that is inclusive of social ecological determinants, such as stigma and discrimination reduction in clinics, is critical for reducing HIV among adolescent girls and young women. Methods: This project involves both a Community Collaborative Board and a Youth Advisory Board in helping to adapt the Young Women's Health CoOp intervention and the Health Policy Project (HPP) Stigma and Discrimination (S&D) reduction training curriculum to the setting and population. This study uses a two-by-two factorial design with stratified randomization of 12 clinics, each with distinct catchment areas. The Young Women's Health CoOp addresses substance use, sexual risk, violence prevention and sexual negotiation, condom demonstration, and problem solving with the following additions: knowledge of PrEP, the importance of PrEP adherence, and sexual and reproductive health. Adolescent girls and young women will be assessed with behavioral and biological measures at baseline, 3-, 6- and 9-month follow-up. The S&D reduction training is provided for all staff in the clinics randomized to this condition. Clinic staff will be surveyed at baseline, 4- and 8-month follow-up. We will recruit 900 AGYW from communities in the 12 clinic catchment areas. Discussion: The study findings, if efficacious across the outcomes, will be incorporated into the gender-focused HIV prevention intervention toolkit and disseminated to inform multilevel prevention approaches. Trial registration: ClinicalTrials.gov. Identifier: NCT04048551 (Recruiting). Registered: August 7, 2019 (Retrospectively registered)