Background
More than 30 years has passed since the quest began for the discovery and cure for HIV. During these years, numerous behavior change, risk-reduction, and biomedical interventions have been developed and tested. Some have proven efficacious in randomized controlled trial and field settings; however, it often takes almost two decades for these evidence-based interventions to be translated into practice [
1]. Despite these advances, South Africa continues to have among the highest prevalence of HIV globally [
2] and a persistently high rate of HIV incident cases [
3]. HIV is most commonly transmitted heterosexually in South Africa and it is concentrated disproportionately among women of childbearing age [
3]. Women are more vulnerable than men because they are more susceptible anatomically and because gender inequality and intimate partner violence (IPV) are prevalent in South Africa; well-documented risk factors for HIV acquisition [
4] that make it difficult for women to negotiate condom use with male sex partners [
5].
Alcohol and other drug (AOD) use is also highly prevalent in South Africa. Estimates indicate that 13% of the South African adult population will meet diagnostic criteria for a substance use disorder in their lifetime [
6], and the country has among the highest rates of hazardous and harmful alcohol use globally [
7,
8]. Vulnerable women may cope with their marginal position in South African society by using AODs [
5,
9], which contributes to HIV transmission [
10,
11] by decreasing condom use and increasing risky sex behaviors [
10]. For example, women may use AODs to cope with sex trading, which increases multiple risks for HIV exposure, or they may trade sex for AODs or for life necessities [
12]. For women living with HIV, AOD use also has a negative impact on HIV treatment initiation and antiretroviral therapy (ART) adherence [
13‐
15], and because AOD use is associated with risky sex behavior it increases the likelihood of onward transmission of HIV [
16]. Consequently, there is a public health imperative to reduce AOD use and associated sex risk behavior among women living with HIV.
Several interventions have sought to address AOD use, risky sex behaviors and/or IPV among people living with or at risk for acquiring HIV in South Africa [
17‐
20]. However, none of these interventions has targeted vulnerable women while addressing the nexus of these behaviors. A recent review argued that where AOD-using women face multiple and syndemic risks for HIV, including risky sex behaviors and IPV, evidence-based woman-focused interventions are needed to prevent new incident infections [
21,
22]. The Women’s Health CoOp (WHC) is one such evidence-based woman-focused intervention.
The Women’s Health CoOp
Based on the original Women’s CoOp, which was developed for use with African American women who use AODs [
23], this two-session best-evidence empowerment-based intervention [
24] has been adapted for use among vulnerable South African women [
25‐
27]. The WHC is a cue-card delivered intervention that combines risk-reduction information for AODs, HIV and other sexually transmitted infections, and gender-based violence with behavioral skills training for sexual protection and safer sex communication. The adaptation for this study is being delivered in group format by a trained clinic interventionist. Each session lasts approximately 60 min, depending on the length of the discussion, role playing, and rehearsal of skills. See Table
1 for an overview of the WHC.
Table 1
Overview of the WHC
Session I |
• Why is reaching women so important? | • Concerns about HIV testing | ACTIVITY: |
• Reasons women are at risk in South Africa | • Meaning of HIV test results | STI photos |
• How do women get infected with HIV? | • South Africa has a very high rate of | ACTIVITY: |
• What we want you to know about HIV | TB coinfection | Practice using male/female condoms |
• Myths and truths about HIV/AIDS | • Preventing the spread of HIV | |
• CD4 and viral load tests/ART | • Male and female condoms | ACTIVITY: |
• Do you know what STIs look like? | • Oral protection for women | Roleplay sexual negotiation |
• Keeping your private parts healthy | • Reducing sex risks |
• Circumcision decreases risk | • Negotiate for sexy safer sex |
Session II |
• Alcohol and drug abuse in South Africa | • Responses to conflict (fair fighting) | ACTIVITY: |
• Alcohol and drug use compromises | • Concerns about abuse of women | Roleplay problem solving |
behavior | • Myths and truths about abuse |
• Why is alcohol so risky for women? | • Rape and violence prevention | ACTIVITY: |
• Alcohol and drugs affect unborn babies | • Sexual safety | Personalized Action Plan for women |
• Facts about drug use and injection risk | • Problem-solving steps for life |
• Having a balanced life | • Standing your ground |
• Reducing alcohol and drug risks | • Stay alert, stay powerful |
• Harm reduction strategies | • Benefits of support: sister to sister |
• Benefits of rehab | • Women can become powerful |
Several randomized field trials have found the WHC to be efficacious for reducing AOD use and sex risk behavior among vulnerable women in South Africa [
25‐
28], suggesting that the WHC could help prevent incident infections among vulnerable women if scaled up and implemented more widely.
Publicly funded primary healthcare (PHC) clinics that provide free HIV testing and counseling (HTC), antenatal care and free ART are often next door to substance abuse rehabilitation, or rehab, services. Consequently, using these services for women living with HIV is logical and provides convenient settings for implementing the WHC. However, prior to introducing the WHC into these settings, it is essential to determine whether it is feasible to implement this program in these settings given that they often are under resourced and may not be able to respond to barriers and access to public health services [
29,
30]. Identifying potential barriers and facilitators is key to assessing appropriateness, and necessary for adoption [
31]. Additionally, understanding the context of the implementation settings may also enhance the feasibility and acceptability of the intervention, which may result in the sustainability of its adoption [
31,
32]. Consequently, identifying barriers, facilitators, and any adaptations is a critical first step in the implementation science process [
33].
This study presents a first step toward examining the acceptability and feasibility of implementing the WHC in PHC clinics and substance abuse rehab settings in Cape Town, South Africa. Specifically, it explores perceived barriers and facilitators from service providers, key informants, and women on acceptability and how the intervention will need to be adapted to facilitate implementation.
Methods
Design
This paper presents the formative, qualitative phase of an implementation hybrid type II study [
34]. We conducted focus group discussions (FGDs) with women who use substances and with service providers, we also conducted in-depth interviews (IDIs) with health service planners at local and provincial levels. Our goal was to examine implementation and clinical outcomes associated with delivery of the WHC across PHC clinics and substance abuse rehab programs. This study utilized FGDs to capitalize on within-group dynamics with the women and providers. FGDs with government officials and health service planners was not feasible therefore IDIs were conducted for these participants.
Participant recruitment and setting
In this initial formative stage, we only conducted two FGDs with women who use substances (
n = 23), two FGDs with substance abuse rehab providers (
n = 15), and two FGDs with PHC providers (
n = 22). See Table
2 for detailed characteristics of FGD participants.
Table 2
Focus group discussion (FGD) and individual-expert interview (IDI) participant demographic characteristics
Participants | 23 | 22 | 15 | 15 |
Gender | 23 Female 0 Male | 21 Female 1 Male | 14 Female 1 Male | 11 Female 4 Male |
Ethnicity | 22 Coloured 1 Black African | 14 Coloured 6 Black African 1 White 1 Not Reported | 8 Coloured 3 Black African 3 White 1 Asian | 7 Coloured 1 Black African 7 White |
Age Range | 19−34 | 27−51 | 23−51 | Not collected |
Description | Women living with or vulnerable to acquiring HIV who use substances | Senior workers, nurse practitioners, clinical managers, counselors, nurse assistants, adherence counselors, senior therapists | Social workers, therapists, treatment coordinators, counselors, program managers, interns | City of Cape Town mayoral committee members, provincial department of health HIV directorates, substance use services managers and treatment directors, department heads, project managers, treatment supervisors, chief directors of health, women’s health managers, provincial ministers |
Women were recruited using established street outreach methods proven successful in previous studies for recruiting vulnerable women in Cape Town [
35,
36]. Project staff marketed the study in PHC clinics, substance abuse rehab programs, and locations in surrounding disadvantaged communities served by these facilities where potentially eligible women frequent. To be eligible, a woman had to be between the ages of 18 and 35, be Black African or Coloured (mixed ethnicity), have used AODs at least weekly during the past 60 days, had sex with a male partner in the past 60 days, provide contact information, and be willing to talk in a group of peers.
Project staff met with healthcare providers, explained the study, and recruited them to participate in FGDs. To be eligible, healthcare providers had to be working at a PHC clinic or substance abuse rehab program located within a disadvantaged community and have ongoing interaction with patients who met eligibility criteria for the WHC.
We conducted IDIs with key informant health service planners at local and provincial governmental levels (
n = 15). A list of relevant people in health and social welfare departments was generated based on recommendations from our Community Collaborative Board (CCB) and knowledge of experts in the area (see Table
2).
Data collection
All FGDs were held in private rooms at PHC clinics and in the substance rehab programs. Prior to the start of each FGD, participants provided written informed consent. A focus group guide consisting of open-ended questions with probes was used to clarify points, encourage continuous dialogue, and guide discussion regarding barriers and facilitators. Participants were briefly shown the cue-card-driven WHC intervention. This paper focuses on the FGD topics related to issues of implementing the WHC in the clinic setting from the perspectives of the women and providers. The US-based Principal Investigator and a South African consultant, both psychologists experienced in group dynamics, facilitated the FGDs.
IDIs with health service planners took place in the participants’ offices. Participants provided written informed consent. Interview guides similar to those used in the FGDs guided the interviews. These interview guides also included questions about the availability of services for the target population, and the extent to which HIV services were integrated with substance abuse rehab services. Participants were also shown the WHC intervention.
FGDs and IDIs lasted between 60 and 90 min each, and were audio-recorded and transcribed verbatim.
Data analysis
We analyzed the data using a modified grounded theory [
37] approach informed by Proctor and colleagues’ conceptualization of implementation outcomes [
31]. Two project staff members conducted analyses. First, they created an initial code list based on a preliminary reading of randomly selected transcripts from each participant group. Codes were reviewed and modified during regular meetings between the two project staff members during the process. There were few disagreements regarding the codes. Where disagreements occurred, they were resolved with discussion. Once the two coders had identified a list of primary and secondary codes, they shared the codes and text examples from various transcripts for context with the other members of the research team who further refined the codes. The final coding scheme consisted of four main code families: perceived barriers and facilitators to implementing the WHC; patient barriers; clinical or provider barriers; and operational (or structural) barriers to women seeking treatment or clinicians providing services in general. The current manuscript describes the first code family, perceived barriers and facilitators to implementing the WHC.
We then used a unit of analysis approach [
38] to assess intercoder reliability, which was measured using Kappa. Specifically, both team members coded portions of randomly selected transcripts from each stakeholder group, compared the results, and discussed any disagreements in an effort to reconcile them to reach a final coding decision [
38]. To prevent agreement persuasion, one coder shared a blinded unit of analysis transcript with the codes removed, though the relevant lines of text remained highlighted for the other coder to code. Through this process, some codes, including one primary code, were merged to clarify coding definitions, whereas new codes were added to properly code emerging themes. Prior to merging the fifth primary code, Kappa for intercoder agreement for the primary codes alone was .91. When intercoder agreement was recalculated to account for the merging of the primary code, Kappa was .90.
Discussion
The WHC is a comprehensive woman-focused approach to HIV prevention and care that addresses the trifecta of AOD use, sexual risk, and IPV. The program has been proven efficacious, but has yet to be implemented in real-world clinical settings. In this study, we explored perceived barriers and facilitators likely to be encountered when implementing the WHC in PHC clinics and substance abuse rehab programs in South Africa.
The main finding is that collectively participants in this formative phase voiced their enthusiasm for an intervention such as the WHC and provided insights into the potential barriers that may need to be addressed for the successful adoption of the WHC. More specifically, there is agreement on the need for such a program, given the risk factors faced by women living with HIV and the lack of effective and accessible substance abuse treatment options available for poor and vulnerable women.
Additionally, all clinic staff, women participants, and stakeholders expressed high acceptability of the WHC. Yet they had concerns about potential barriers to women engaging with this program, largely because of the stigma women may experience when seeking services and the lack of person-centered care at healthcare facilities. Specifically, as previous research has indicated [
5,
39], stigma and discrimination are key barriers to women seeking and accessing services for substance abuse and HIV in South Africa.
Another major potential barrier, limited staffing, may impact the ability of clinics to deliver the WHC in addition to their other services. These include the fact that staff members have very little time available to be trained on and to deliver this intervention given their current workload. Additionally, they may not have the requisite skills to deliver this intervention with fidelity.
Finally, participants raised concerns about the length of the intervention and about some of the topics covered in the intervention. This suggests that the intervention content may need to be revised to help insure successful implementation in healthcare settings.
To find potential solutions to these barriers and optimize the implementation of the WHC in healthcare settings, we sought guidance from our CCB, which comprises a diverse group of individuals representing the Department of Social Services and local health departments, alcohol and drug treatment programs, organizations that address victimization and rape, and other community advisors to discuss the progress and challenges of the project. We conducted meetings with CCB members and other key clinic staff to troubleshoot implementation barriers identified during this formative phase of the study.
To address these barriers, the CCB recommended using CCWs rather than nurses to deliver the intervention, mentoring and empowering the CCWs through regular supervision to build capacity to deliver the intervention, and modifying the intervention content to address concerns about intervention length and sensitivity issues raised during the formative phase. Based on the formative findings and feedback from our CCB and clinic representatives, the project team adapted the intervention and modified the implementation procedures to address the participants’ concerns. Specifically, to address sensitivity, the team removed some of the sexually sensitive topics used with previous interventions with sex workers. To address the length of the intervention, some content was reduced, including removing information related to certain drugs that were not relevant to the target clinic populations because typically they are not used in the region. Lastly, to account for staffing constraints in these settings, the study team formed and strengthened partnerships with nongovernmental organizations in Cape Town for on-the-ground support, especially for conducting the intervention.
Limitations
As with most qualitative studies, the findings may not be generalizable to other settings. However, we have observed similar barriers and facilitators in other settings in the Western Cape and Pretoria. Another limitation inherent in preimplementation formative data collection arises from the fact that participants’ responses and opinions are based on limited exposure to the intervention, as reviewing the intervention is not the same as receiving or delivering the intervention. Nonetheless, our formative data provided critical information that we used to modify the process and the intervention, increasing the likelihood of successful implementation.
Conclusion
Given that South Africa has the largest percentage of people living with HIV and a disproportionate number of women of childbearing age bearing the greatest burden of the disease, an evidence-based woman-focused intervention that could help women more comprehensively adhere to ART would seem ideal. However, potential barriers exist to implementing the WHC in healthcare settings in resource-scarce environments because addressing clinical crises may be prioritized over the delivery of this woman-focused program. This may be especially true when the program is newly introduced to the healthcare setting, is seen as an add-on to services currently offered by facilities, and is not fully integrated into the usual services delivered by PHC clinics and substance abuse rehab facilities.
The nature of gender inequality across South Africa may evoke mixed feelings among staff about whether the appropriateness of a woman-focused program is needed for the patients they serve. Especially if they hold negative perceptions and stigmatizing opinions of women who use AODs and hold their attitudes as a barrier to engaging with health services. For implementation of the WHC to be successful, women who use AODs must be willing to seek and engage with health services, and providers must also be willing to serve them. To achieve this, we need to reduce health providers’ stigma and discrimination toward women who use AODs, as well as promote empowerment interventions in a country striving for gender equality.
Acknowledgements
The views and conclusions are those of the authors and do not necessarily reflect the views of the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The funding agency had no role in the research design or the protocol development, or in suggesting publication plans for this article. We thank Jeffrey Novey for his editorial assistance.