Women’s Health Co-Op

The Women's Health CoOp Package (WHC) is a woman-focused HIV intervention program to empower vulnerable women. The overarching aim of the intervention is to address the intersecting risks of [...] use, [...] behaviors,violence, and victimization among hard-to-reach, vulnerable women in disparate communities.

The original evidence-based Women’s CoOp program—developed by Dr.Wendee Wechsberg, Senior Director of the Substance Abuse Treatment, Evaluation and Intervention research program at RTI International—was conducted in North Carolina and then translated and adapted for other populations in North Carolina, Russia, and South Africa. The WHC program has been implemented successfully in a variety of settings and the published WHC research findings supported the packaging of the program to reach many more vulnerable South African women.The WHC Package will help this program reach more groups of vulnerable women in Sub-Saharan Africa by making this HIV prevention intervention more readily available and user friendly.

This woman-focused intervention is organized on the principles of developing personal power by reducing substance use, strengthening negotiation skills for [...] protection, and preventing [...] violence and HIV. It provides access to HIV testing, active referrals to local antiretroviral therapy (ART) and substance abuse counseling services, female and male condoms, and skills in empowerment and negotiating with [...] partners. Participants are provided with realistic, culturally relevant prevention strategies that they apply to their lives.

The goals of the WHC program are to train outreach workers in how to reach vulnerable women and to train peer educators to deliver the intervention in health care settings, mobile units, or other private settings. The program is designed for use in organizations that wish to provide comprehensive HIV prevention, including HIV counseling and testing (HCT), enhancing condom use skills, increasing negotiation skills, and providing substance abuse education and violence prevention for hard-to-reach and vulnerable women. It also addressed HIV status, referrals and adherence to ART.

Key Characteristics

The Women's Health Co-Op has several key components:

• Specific Focus on Women: Focuses on women at risk for HIV because of [...] risk behaviors, substance use behaviors, and/or violence and victimization.
• HIV Testing: Uses comprehensive HCT as a cornerstone element of the program.
• Personalizes Risk: Educates women AbOUT HIV/AIDS, sexually transmitted infections (STIs), alcohol and other [...] use and violence prevention within a cultural context (for example, racially/ethnically or geographically) to personalize risk.
• Community-based Settings: Establishes a community presence where program staff are easily accessible and comfortable with the target group.
• Street Outreach Program: Establishes street outreach involving organization staff or peer volunteers who are knowledgeable about the community to reach women for the WHC.
• Community-based and Peer Program Delivery: Involves recruitment and training of women from the community to deliver the programme.
• Staff Training: Uses the intervention Training Manual and associated program materials to train staff.
• Flexible Program Sessions: Provides women with two individual or group intervention sessions.
• Quality Assurance: Establishes and maintains quality assurance procedures to ensure the program is delivered as intended (program fidelity).
• Distribution of Risk-Reduction Materials: Involves distribution of male and female condoms, water-based lubricants, and other risk-reduction materials to women after each session.

Target Population

Women who engage in high-risk behaviors, including substance use and [...] work.

Intervention Goals

• To reduce [...] risk behavior (including trading [...] for money or drugs and unprotected [...]) and [...] use (such as the number of days drinking and using other drugs) and violence prevention (with main [...] partners and clients).
• To prevent new HIV infection

Theoretical Basis

• Feminist Theory
• Empowerment Theory

The WHC program encourages vulnerable women to gain control over their lives and not give away power because of substance use and [...] risk behaviors. The underlying theory that informs the program is based on the lack of equality for women caused by elements of racism and classism. Taking these factors into account helps provide a more holistic approach to the complex issue of HIV prevention, and consequently allows women to overcome personal and societal barriers to gain control over their lives and decisions about their health.

Effectiveness

• The program is listed in the Centers for Disease Control (CDC) Compendium of Evidence-Based HIV Behavioral Interventions as a best evidence program.
• The 2009 USAID compendium report, Integrated Multiple Gender Strategies to Improve HIV and AIDS Interventions: A Compendium of Programs in Africa, cites WHC-Pretoria as a successful woman-focused, HIV prevention intervention in South Africa.

WHC Intervention Studies

The adaptations of the program use formative research methods in order to incorporate the influence of culture and gender on risky behavior of study participants. Information gathered from the formative research informs the intervention and lessons learned from each study are incorporated into future studies. For example, violence and victimization were addressed in the South African studies, which helped to inform efforts in North Carolina.

• Women's Health CoOp (WHC) IDurham, NC (1998–2002)
  • Client/Agency:NIDA
  • Description: This study examined the effectiveness (at 3- and 6-month follow-up) of a personalized HIV intervention tailored to gender and culture, compared with a standard intervention and a delayed treatment control group, to reduce [...]-risk behaviors and [...] use and increase employment and housing status among African American women who use crack.
  • Findings: All groups significantly reduced crack use and high-risk [...] at each follow-up, but only woman-focused intervention participants consistently improved employment and housing status. Compared with control subjects at 6 months, woman-focused intervention participants were least likely to engage in unprotected [...]; and the women in the revised standard intervention reported the greatest reductions in crack use.
• Pretoria CoOp/Sunnyside Pretoria, South Africa (2001–2003)
  • Client/Agency: National Institute on [...] Abuse (NIDA)
  • Description: This pilot study adapted an HIV prevention intervention program for women in South Africa. In depth interviews and focus groups were conducted with service providers, researchers and female [...] workers who were active substance abusers. These activities were conducted to better understand risk behaviors and determine innovative ways to address these behaviors within a South African woman's life context. A Community Advisory Board was also established and consisted of a cross-section of professionals from nongovernmental organizations (NGOs), nonprofessionals, service providers and researchers. All these activities helped to inform the adaptation of the original Women's CoOp intervention program, which was conducted in the United States, into an intervention for South African women.
  • Findings: The findings demonstrated that outreach to active substance abusers in South Africa is possible and that brief interventions can promote HIV and substance use risk reductions.
• Women's Health CoOpPretoria, South Africa (2003–2009)
  • Client/Agency: National Institute on Alcohol Abuse and Alcoholism (NIAAA)
  • Description: The primary objective of this community-based, randomized controlled trial study tas o understand the relationship between alcohol and other [...] use,violence against women, and HIV risk. The WHC-Pretoria study also examined whether a woman-focused intervention can help women not only reduce risks associated with HIV, but also address personal goals, such as homelessness and unemployment, that could change the course of their lives.
  • Findings: The study findings indicated significant reductions in levels of alcohol, [...], and crack [...] use at the 3- and 6-month follow-ups. Women also reported continuous decreases in main partner violence at each follow-up. A significant increase in the percentage of women using condoms with main partners at last [...] and the proportion who used condoms in the past 90 days, even under the influence of drugs was also observed.

• Women's Health CoOp IIDurham, NC (2004–2007)
  • Client/Agency: NIDA
  • Description: The NC Women’s CoOp II (hereafter, Women’s CoOp II) was a NIDA competing continuation study of the Women’s CoOp. The specific aims of Women’s CoOp II were to assess the long-term effects of the Women’s CoOp I interventions and to assess the impact of adding booster sessions. Baseline enrollment in the Women’s CoOp II began in 2004, 2 years after the last follow-ups from Women’s CoOp I (2002), and ended in 2007. Follow-up interviews for the Women’s CoOp II project were completed at 6, 12, and 18 months post-enrollment.
  • Findings: The analyses revealed two distinct groups at short-term follow-up (STFU): women who either eliminated or greatly reduced their risk behaviors (low-risk class) and women who retained high levels of risk across multiple risk domains (high-risk class). At STFU, women in the woman-focused intervention were more likely to be in the low HIV risk group than the women in control conditions, but this effect was not statistically significant at long-term follow-up (LTFU). However, low-risk participants at STFU were less likely to be retained at LTFU, and this retention rate was lowest among women in the woman-focused intervention.
• Cape Town Women's Health CoOp Cape Town, South Africa (2004–2005)
  • Client/Agency: NIDA
  • Description: Introduced as a brief, gender-based, HIV prevention intervention with [...]-using women—the Cape Town-WHC was adapted from the Women's CoOp for both Black African and Coloured South African women in the Western Cape of South Africa and used both individual and group formats. The primary aim of this pilot randomized trial was to examine whether the adapted Women's CoOp intervention- the Cape Town-WHC- would be equally or more or less effective at reducing substance use, HIV risk, and violence when delivered using an individual or group format. The secondary aim was to examine the differences between Black and Coloured South African women across pre- and post-intervention measures of alcohol and illicit [...] use and [...] risk behaviors. This study described the differences in both groups of women in [...] use and [...] risk, post-intervention changes, and model assignment effects.
  • Findings: Despite significant differences in observed risk behaviors between Black and Coloured South Africans, both ethnic groups were responsive to the adapted intervention and no differences were found by intervention assignment (individual and group assignment).
• Woman-Focused HIV Prevention with Pregnant African-Americans in Treatment: Pregnant Women's CoOp North Carolina (2006–2010)
  • Client/Agency: NIDA
  • Description: African-American women who are pregnant and substance users need comprehensive programs to reduce the risk to them and their unborn children. Evidence-based HIV interventions have been developed for African-American women, but few have targeted women in substance abuse treatment. The findings from HIV prevention research conducted with pregnant women who use alcohol and other drugs demonstrate that personalized interventions increase self-awareness of HIV risks and are more effective than generic educational interventions. This project adapted the WHC program to pregnant women in substance abuse treatment programs. The intervention addresses the intersection of substance use behavior, [...] risk behavior, and victimization.
  • Findings: The main findings included reductions in homelessness, [...] and other illicit [...] use, and incidence of physical violence, and an increase in HIV knowledge from baseline to follow-up at 6-months post-intervention. This study also filmed vignettes of women’s most memorable stories, which informed other studies.
• Western Cape Women's Health CoOpPretoria, South Africa (2007–2012) .
  • Client/Agency: National Institute of Child Health and Human Development (NICHD)
  • Description: This community-based effectiveness study builds on findings from the recently completed Cape Town Women's Health CoOp pilot study (2004–2006). In collaboration with the South African Medical Research Council, this study was designed to reach a larger sample of women than via a full-scale study by adding a woman-focused intervention after voluntary counseling and testing (VCT). A randomized controlled trial was used to test the effectiveness of combining VCT with a woman-focused intervention in helping women reduce their substance abuse, [...] risk, and victimization compared with two control groups, a VCT-only group and an equal-attention (nutrition) group.
  • Findings: This brief intervention when added to counseling and testing resulted in greater abstinence of [...] use at the 12-month follow-up. It also resulted in a larger percentage of [...] activity not under the influence of substances among women in the woman-focused with VCT intervention group than women in the other two groups.
• Women's CoOp–Russia: Adapting the Women's CoOp for Injecting [...]-Using Women in Russia St. Petersberg, Russia (2007–2009)
  • Client/Agency: NIDA
  • Description: Partnering with the Leningrad Regional Center of Addictions, this study pilot-tested an adaptation of the Women's CoOp HIV prevention intervention among female injecting [...] users (IDUs) in St. Petersburg, Russia. To be eligible for the study, an individual had to: (a) be female, (b) have injected drugs in the past year, (c) currently be in substance abuse treatment, (d) be between the ages of 18 and 30 years old, (e) consent to participate in the study, and (f) provide locator information for follow-up assessment in the St. Petersburg area. The 100 female IDUs recruited for this study were randomized into one of two study groups, and received either the woman-focused intervention or a nutrition intervention (an attention-control). Among study participants, 91% completed the 3-month follow-up assessment.
  • Findings: The study data indicated a high level of HIV prevalence and use of dead-space syringes, with high frequency of injecting among participants. There was also evidence to support the woman-focused intervention with regard to reducing unprotected [...] acts and always using clean injection equipment. In this pilot study, harm reduction interventions were largely successful for the woman-focused group (e.g., clean injection practices and protected [...]).
• Young Women's CoOp TEENS North Carolina (2007–2013)
  • Client/Agency: Centers for Disease Control and Prevention (CDC)
  • Description: Data from the Women's CoOp studies show that African-American women in North Carolina are at risk for dropping out of school, using drugs, and becoming sexually active in their adolescence. For these reasons, the Young Women's CoOp study was proposed to target this at-risk population. The Young Women's CoOp is a 5-year study to adapt the Women's CoOp (a "best-evidence" behavioral HIV prevention intervention) for at-risk African-American females between the ages of 16 and 18 in North Carolina. The adapted intervention addresses knowledge of HIV and sexually transmitted infections (STIs); health consequences of substance use and abuse, building healthy relationships with male partners and females; condom negotiation and communication with partners; positive social supports; gang and violence prevention methods; and HIV, STI and pregnancy risk-reduction. During the formative phase of the study, which was recently completed, we solicited input from young women and other community stakeholders in Raleigh-Durham on how to best adapt the Women's CoOp intervention to target population. A Teen Advisory Board was convened to provide the study team with gender-, age- and culturally specific information to adapt the intervention for young African American women.
  • Current Status: The study was recently completed. Findings are being evaluated and written up for dissemination.
• Combination Prevention for Vulnerable Women in South Africa Pretoria, South Africa (2011–present)
  • Client/Agency: NIDA
  • Description: This study will explore whether integrating a behavioral-focused, HIV-prevention strategy with a biomedical intervention will maximize the efficacy of both strategies and improve HIV treatment and prevention outcomes among women who use alcohol and other drugs (AOD) in Pretoria, South Africa.
    • The specific study aim is to test whether adding the Women's Health CoOp to standard HIV counseling and testing and PEPFAR practices results in more HIV-positive AOD-using women getting medical evaluations (i.e. CD4, viral load), starting treatment, staying in treatment, and reducing risk behaviors (i.e. reduced substance use, improved condom use practices, reduced victimization).
  • Current Status: Steady recruitment continues.