Reducing the Transmission of HIV and Sexually Transmitted Infections in a Mining Community

This 46-page evaluation explores the implementation and impact of a communication-centred intervention study/project launched by the United-States-based Horizons Program/Population Council in 1998 in the mining town of Carletonville, South Africa. Working with the Center for Scientific and Industrial Research (CSIR), the South African Institute for Medical Research (SAIMR), and the London School of Economics (LSE), Horizons sought to investigate the social determinants of the HIV epidemic and to assess the impact of a targeted programme of HIV and sexually transmitted infection (STI) prevention and service delivery. This report describes the Mothusimpilo ("working together for health") Intervention Project (MIP), detailing the process of its implementation - and its impacts.

As detailed here, MIP drew upon information, education, and communication (IEC) activities, as well as the provision of STI services, in an effort to reduce (in a sustainable way) the community prevalence of STIs and the incidence of HIV infection. The interventions, which focused primarily on female sex workers (SWs) and male mine workers, involved 3 primary components:

1. peer education on HIV/STI knowledge and prevention - A number of SWs were recruited and trained in community work, hygiene, HIV/AIDS, and signs and symptoms of STIs. They provided information to other SWs, and to a limited extent, the community at large. A similar programme was designed to address mine workers who were perceived to be the primary clients of SWs;
2. free condom promotion and distribution to SWs and mine workers by peer educators; and
3. efforts to strengthen STI services at private and public health facilities in Carletonville through the training of service providers in STI case management. In addition, beginning in 2000 SWs were able to enroll in a presumptive treatment programme for gonorrhoea and chlamydia; this was part of an effort to foster improved management of STIs, including periodic presumptive treatment (PPT).

Excerpts from the Executive Summary follow:

"This report is based on qualitative and quantitative findings from different data collection activities including:

• A pre-intervention survey (1998) of a random, representative sample of 489 men and 710 women from the Khutsong community, 121 SWs from established sex worker venues or “hotspots,” and 898 mine workers.
• A post-intervention survey (2001) of 532 men and 878 women, 101 SWs, and 998 mine workers from the same communities as those sampled for the pre-intervention survey.
• Focus group discussions (FGDs) and interviews with SWs to learn more about sexual behavior and networks.
• FGDs and interviews with members of social organisations to understand the role they play in HIV prevention and sexual risk.
• Two assessments of the quality of care of STI services provided by the public, private, and mining sectors and traditional healers (1999 and 2000).

The two surveys allowed for comparison between baseline (pre-intervention) data collected in 1998 and endline (post-intervention) data collected in 2001....The survey data were complemented by other data on the quality of STI services in Carletonville, the protective and risk factors of social organisations, and sexual behaviour and partnerships among SWs...

Key findings

Knowledge of HIV transmission

Knowledge of HIV transmission was high at baseline and increased further by 2001. Although fewer respondents answered questions correctly when asked about erroneous modes of HIV transmission (e.g., whether mosquitoes transmit HIV) at baseline compared to other knowledge questions, there was improvement in these items among all groups by 2001. Widespread HIV/AIDS messages from multiple sources and the fragmented peer education programme among mine workers made it impossible to attribute increases in HIV transmission knowledge solely to the MIP information, education, and communication activities.

HIV prevalence

Between 1998 and 2001, with the exception of men in the community, all groups experienced an increase in HIV prevalence. HIV prevalence among mine workers increased significantly from 29 percent to 36 percent (p .001). It also increased among SWs from 69 percent to 78 percent. Prevalence levels significantly increased among women in the community, rising from 37 percent to 45 percent (p .001). Men in the community experienced a slight decrease from 22 percent to 20 percent.

STI prevalence

Despite administration of PPT for bacterial STIs among SWs over a period of 18 months and training of providers for improved STI services, the prevalence of STIs among SWs, mine workers, and men in the community remained constant or slightly increased. Significant increases were noted among women in the community between 1998 and 2001...

Number of sexual partners

From 1998 to 2001 the percentage of mine workers reporting one or more casual partners in the 12 months prior to each survey decreased significantly from 53 to 43 percent (p .001). The proportion of men in the community reporting that they had one or more casual partner in the previous 12 months increased from 37 to 45 percent. In 2001, 41 percent of women in the community reported having casual partners, which was significantly higher than the figure of 24 percent reported in 1998 (p .001).

Condom use

Reported consistent condom use with casual partners increased significantly from 1998 to 2001 among mine workers (19 to 24 percent, p = 0.02) and men in the community (28 to 37 percent, p = 0.04). Among women in the community it increased only slightly, from 22 percent to 25 percent. The proportion of SWs who reported using a condom with their last casual partner did not increase over the survey period. Very few mine workers reported always using a condom with their regular partner (6 percent in 1998 and 4 percent in 2001). The percentage of SWs using condoms consistently with regular partners decreased from 26 percent to 12 percent. Consistent condom use with regular partners among men (9 percent in 1998 and 6 percent in 2001) and women (6 percent in 1998 and 5 percent in 2001) in the community remained low.

Quality of STI services

There remains room for improvement in the quality of treatment of STIs in both the public and private sector. Further training is needed in the treatment of warts, herpes, buboes, and genital ulcers. Rational drug use and over-prescription in the public sector also need to be addressed. Both mine workers and men in the community reported frequently seeking care for STIs from traditional healers due to the quality of care that they provide. Traditional healers were systematically included in the STI training provided by the project.

Role of sexual networks

Analysis revealed that sexual networks in Carletonville were more complex than originally believed, linking mine workers, SWs, men, and women in the community...

Role of social organisations in HIV risk

Depending on the type of organisation, membership was found to be associated with either a greater or lesser level of HIV risk. For example, men in the community who were members of a sports group were found to be at a reduced risk for HIV infection. Similarly, women in the community and mine workers who were active church members were less likely to be HIV positive. Membership in stokvels (informal rotating credit schemes), political parties, and burial societies was associated with higher risk behavior, in particular having an increased number of sexual partners. Qualitative discussions found that churches and youth and sports clubs promoted good moral behaviour, while stokvels, political parties, and burial societies were linked with wild parties where alcohol consumption and risky sexual behaviour were the norm. However, it is not clear whether these findings are a result of self-selection of individuals into particular groups or a result of group norms and values in those organisations influencing the behaviour of members.

Project management and community participation

Initial funding of the project ended in 2001, but the MIP has persevered as a community project. Local stakeholders continue to be key players, as are the mine workers. This private-public sector partnership has provided the project with the financial support and management skills needed to sustain MIP.

Conclusions

The MIP did not reduce STI prevalence or HIV prevalence. Given the high HIV prevalence rates in 1998, especially among SWs and women in the community, the challenge was great. Further, interventions among mine workers were delayed and not implemented with sufficient intensity. For both SWs and mine workers, 100 percent condom use was not achieved. This situation was aggravated by the complex sexual networks between mine workers, SWs, and the community, which may have limited the impact of PPT among SWs and behavioural change interventions targeting both SWs and mine workers. Despite interventions to address the quality of STI treatment, respondents in Carletonville did not always receive appropriate treatment for a variety of STI conditions.

Changing sexual behaviour is far more complex than educating individuals about HIV. More comprehensive peer education was implemented for SWs, but it failed to achieve universal condom use among SWs. The absence of a sustained peer education programme for men in the community and in the mines meant that men were receiving limited information and support regarding behaviour change. It is possible that the condom distribution activities among mine workers could have contributed to the increase in mine workers' reported use of condoms with their last casual partner.

Recommendations

The recommendations that emerged from this project are relevant for other large-scale community projects, particularly in settings with high HIV and STI prevalence rates.

Behavioural change education

• The MIP should coordinate peer education programmes for all target and sub-populations involved in sexual networks in the area.
• The programme should examine the effectiveness of promoting condom use among women without a comprehensive programme for men, given women’s lack of power to negotiate safer sex in many contexts...

STI treatment

• It is critical to analyze the pattern of STIs and sexual networks in the community prior to the introduction of interventions.
• To have greater impact on STI prevalence, the MIP should carefully explore different options to address STIs among the regular partners of SWs and among high-risk women in the community...
• Attention to quality of STI services should continue to be a key focus of the MIP. Even when services are accessible, clients may not use them due to concerns about the quality of care provided, privacy, and stigma.
• The preventive component of the MIP should be integrated with other community programs focusing on HIV voluntary counseling and testing, care and support, and treatment services.

The role of social organisations

• The MIP should develop innovative ways to harness the positive aspects and to reduce the negative influences of group membership in social and community organisations. This could involve training organisation leaders to share accurate information and advice to their members about HIV/AIDS.

Stakeholder participation and community mobilisation

• The MIP should continue to cultivate partnerships between the community and the private sector, as this relationship is crucial for greater acceptance of the project and its long-term sustainability.
• The MIP should endeavor to develop good governance culture, and the private sector should help develop good project management skills for community stakeholders."