Perceptions of perinatal alcohol use and treatment needs in Cape Town, South Africa: a qualitative study

Background: South Africa has one of the world’s highest rates of foetal alcohol spectrum disorders (FASD). Recent evidence also showed that alcohol use during lactation significantly compromises child development in children exposed to alcohol through breastfeeding, independent of prenatal alcohol exposure. This study explored perceptions of perinatal alcohol use and treatment needs in Cape Town, South Africa, to inform the development of an intervention to encourage alcohol abstinence during pregnancy and breastfeeding. Methods: Individual in-depth interviews (IDIs) were conducted with women who were pregnant with a recent history of alcohol use (n=32) and clinic and community stakeholders (n=16). Interviews were audio recorded and transcribed verbatim. Coding and thematic analyses were conducted in NVivo 12. Results: Results indicate widespread perception that women know the dangers of drinking alcohol while pregnant with much less known about drinking while breastfeeding. Mixed views were shared about whether women who are pregnant or breastfeeding experience alcohol-related stigma. Participants described contextual factors impacting drinking that include interpersonal violence, lack of support, stress, anxiety and poverty, and drinking being normalised. Finally, participants had mixed views and conflicting knowledge of available resources to support alcohol reduction and highlighted a desire for support groups and the involvement of partners in alcohol interventions. Conclusions: Findings from this study highlight the need for an alcohol intervention programme that is innovative and tailored to the needs of women who are pregnant or postpartum. It also highlights the importance of including community-based support and partner involvement in these interventions

Development of a trauma-informed substance use and sexual risk reduction intervention for young South African women

Purpose: To develop a trauma-informed substance use and sexual risk reduction intervention for young South African women at risk of HIV. Patients and methods: Guided by the ADAPT-ITT framework for intervention development, we selected four focus groups (n=26) to assess the service needs and preferences of trauma-exposed young women (aged 18–25 years) who use substances. We used findings to develop a needs-based and contextually appropriate intervention. In addition four focus groups (n=30) were selected to explore potential service users’ views of this intervention and recommendations for improving acceptability and appeal. Expert stakeholders were also consulted. Results: Young women described therapeutic, self-care, and social support needs for coping with traumatic experiences and reducing substance-and sexual-related risks for HIV and further trauma. To address these needs, we expanded the Women’s Health Co-Operative (WHC; an evidence-based HIV prevention program) to include trauma-related psychoeducation; cognitive-behavioral strategies for coping with the emotional impact of trauma, stress, and substance use craving; social support strategies; and self-care components to help young women create a life with purpose. This novel and expanded six-session group-based intervention is called the trauma-informed WHC. Focus group participants and expert stakeholders viewed the trauma-informed WHC as highly relevant and acceptable. They provided recommendations for modifications to the intervention structure and reformatting of intervention materials to enhance the intervention’s appeal and the feasibility of reaching and retaining young women in the program. Conclusion: Engaging women as potential service users in the process of developing a trauma-informed substance use and sexual risk reduction intervention helped identify service needs not commonly addressed in trauma-informed substance use interventions but critical for recovery and local relevance. It also enhanced the acceptability and appeal of the intervention. While potentially acceptable, the trauma-informed WHC requires feasibility testing before establishing its efficacy in a larger trial

A trauma-informed substance use and sexual risk reduction intervention for young South African women: A mixed-methods feasibility study

Objectives: Sexual and physical trauma and substance use are intersecting risks for HIV among young women. This study assesses the feasibility, acceptability and preliminary effects of a novel trauma-informed substance use and sexual risk reduction intervention for young South African women. Design: A single arm feasibility test and qualitative interviews of participants. Participants: Sixty women, between 18 and 25 years of age, who reported trauma exposure, substance use and recent condom-less sex were recruited. Twenty participants were randomly selected for qualitative interviews. Intervention: A six-session group-based intervention. Main outcome measures: We examined the proportion of women who provided consent, completed counselling and were retained in the study. Qualitative interviews explored intervention acceptability. Preliminary effects of the intervention on substance use, mental health (depression, psychological distress and trauma symptoms) and sexual risk outcomes (STI symptoms, number of partners and condomless sex) were explored. Results: Of the 66 eligible women, 91% were enrolled. Intervention completion rates were low; 35% attended all sessions. On average, participants attended four sessions (M=3.8, SD=1.3). A 93% follow-up rate was achieved at the 3-month endpoint. In this single group design, reductions in the proportion of participants who tested positive for methamphetamine, cannabis and methaqualone were observed at the 3-month endpoint. Symptoms of depression, psychological distress and trauma; number of STI symptoms; and number of sexual partners also decreased. Outcomes were similar for participants who completed up to four and those who completed five or more sessions. Participants thought the intervention was highly beneficial and proposed modifications to enhance acceptability. Conclusions: This novel intervention seems acceptable and holds potential benefits for trauma-exposed women who use substances. Truncating the intervention may enhance the likelihood of its implementation. The efficacy of the intervention for improving substance use, sexual risk and mental health outcomes requires testing in a controlled design

Relationship power, communication, and violence among couples: Results of a cluster-randomized HIV prevention study in a South African township

Background: Inequitable gender-based power in relationships and intimate partner violence contribute to persistently high rates of HIV infection among South African women. We examined the effects of two group-based HIV prevention interventions that engaged men and their female partners together in a couples intervention (Couples Health CoOp [CHC]) and a gender-separate intervention (Men’s Health CoOp/Women’s Health CoOp [MHC/WHC]) on women’s reports of power, communication, and conflict in relationships. Methods: The cluster-randomized field experiment included heterosexual couples from a high-density South African township in which neighborhoods were randomized to one of the intervention arms or a control arm that received the WHC only. Participants completed in-person study visits at baseline and 6-month follow-up. We examined group differences using one-way analysis of variance and multivariable regression models. Results: Of the 290 couples enrolled, 255 women remained in the same partnership over 6 months. Following the intervention, women in the CHC arm compared with those in the WHC arm were more likely to report an increase in relationship control (β =0.92, 95% confidence interval [CI]: 0.02, 1.83, P=0.045) and gender norms supporting female autonomy in relationships (β =0.99, 95% CI: 0.07, 1.91, P=0.035). Women in the MHC/WHC arm were more likely to report increases in relationship equity, relative to those in the CHC arm, and had a higher odds of reporting no victimization during the previous 3 months (MHC/WHC vs WHC: odds ratio =3.05, 95% CI: 1.55, 6.0, P=0.001; CHC vs MHC/WHC: odds ratio =0.38, 95% CI: 0.20, 0.74, P=0.004). Conclusion: Male partner engagement in either the gender-separate or couples-based interventions led to modest improvements in gender power, adoption of more egalitarian gender norms, and reductions in relationship conflict for females. The aspects of relationship power that improved, however, varied between the couples and gender-separate conditions, highlighting the need for further attention to development of both gender-separate and couples interventions

Methamphetamine use and sexual risk behaviour in cape town, South Africa: A review of data from 8 studies conducted between 2004 and 2007

Objective: Community studies and studies of admissions to drug treatment centers indicate a dramatic increase in the prevalence of methamphetamine use in Cape Town since 2003. There has also been a substantial increase over this time period in the prevalence of HIV infection among women attending public antenatal clinics in the Western Cape province. This study aimed to review research conducted in Cape Town on the link between methamphetamine use and sexual risk behaviour. Method: A review of published research conducted in Cape Town between 2004 and 2007 was undertaken using PubMed, EBSCOhost and Science Direct. Results: Eight studies were identified, both quantitative and qualitative, and focusing on diverse populations, such as learners in school, out of school youth, adults in the community, men who have sex with men and sex workers. The total sample across the studies was 8153. Across multiple studies methamphetamine was fairly consistently associated with early vaginal sex, condom use during sex, having casual sex and other HIV risk behaviours. For some sub-groups the direction of the relationship was in an unexpected direction. Conclusion: The consistency of the findings across studies highlights the increased risk for contracting HIV among methamphetamine users, and reinforces the importance of interventions addressing both methamphetamine use and unsafe sexual behaviour among young people and other sectors of the population. The need for further research is also considered, particularly research that will explain some of the racial differences that were found

A brief intervention for drug use, sexual risk behaviours and violence prevention with vulnerable women in South Africa: A randomised trial of the Women's Health CoOp

Objective: To assess the impact of the Women's Health CoOp (WHC) on drug abstinence among vulnerable women having HIV counselling and testing (HCT). Design: Randomised trial conducted with multiple follow-ups. Setting: 15 communities in Cape Town, South Africa. Participants: 720 drug-using women aged 18-33, randomised to an intervention (360) or one of two control arms (181 and 179) with 91.9% retained at follow-up. Interventions: The WHC brief peer-facilitated intervention consisted of four modules (two sessions), 2 h addressing knowledge and skills to reduce drug use, sex risk and violence; and included role-playing and rehearsal, an equal attention nutrition intervention, and an HCT-only control. Primary outcome measures: Biologically confirmed drug abstinence measured at 12-month follow-up, sober at last sex act, condom use with main and casual sex partners, and intimate partner violence. Results: At the 12-month endpoint, 26.9% (n=83/309) of the women in the WHC arm were abstinent from drugs, compared with 16.9% (n=27/160) in the Nutrition arm and 20% (n=31/155) in the HCT-only control arm. In the random effects model, this translated to an effect size on the log odds scale with an OR of 1.54 (95% CI 1.07 to 2.22) comparing the WHC arm with the combined control arms. Other 12-month comparison measures between arms were non-significant for sex risk and victimisation outcomes. At 6-month follow-up, women in the WHC arm (65.9%, 197/299) were more likely to be sober at the last sex act (OR1.32 (95% CI 1.02 to 1.84)) than women in the Nutrition arm (54.3%, n=82/152). Conclusions: This is the first trial among drug-using women in South Africa showing that a brief intervention added to HCT results in greater abstinence from drug use at 12 months and a larger percentage of sexual activity not under the influence of substances

Gender and Context Matter: Behavioral and Structural Interventions for People Who Use Alcohol and Other Drugs in Africa

Heavy alcohol consumption and other drug use are prominent across Africa and increase the risk of exposure to violence, HIV acquisition, and other life-threatening injuries. This review synthesizes evidence on alcohol and other drug (AOD) interventions in Africa; evaluates the differences between interventions that do and do not specifically target populations that use AODs; and highlights the impact of comprehensive vs. brief interventions and those that address syndemic issues from a gender and contextualized lens. Literature searches were conducted to identify research outcomes of randomized interventions published between January 2010 and May 2022 that address AOD use in Africa. Thirty-five full-text articles were included in this review. Most of the identified research studies were concentrated in a few countries. Most studies were conducted in South Africa. Many of the studies comprised brief interventions. However, the most comprehensive interventions were the most effective for AOD outcomes. Several studies indicated the importance of addressing AOD use alongside gender-based violence, mental health needs, gender roles, and other social determinants that affect health outcomes. Intervening on AOD use and addressing social determinants from a gender and contextually relevant perspective is essential to ensuring the long-term health and well-being of people in Africa