Policy analysis“Not on the agenda”: A qualitative study of influences on health services use among poor young women who use drugs in Cape Town, South Africa
Introduction
Despite decades of investment in HIV prevention and treatment, South Africa has a persistently high rate of HIV incident infections (Shisana et al., 2014). Nearly a third of all new infections are among poor young women aged 15–24, who seroconvert earlier (Shisana et al., 2014) and have up to eight times greater HIV prevalence relative to their male peers (Dellar, Dlamini, & Abdool Karim, 2015). Consequently, preventing HIV infection in this vulnerable group is essential for achieving epidemic control.
Multiple efforts to prevent HIV among this population have been employed; however, these efforts have largely focused on individual behaviour change, such as increasing condom use. More recently, there has been growing acknowledgement that for HIV prevention efforts to succeed, it is critical to understand the physical and social space in which young women's HIV risk behaviour occurs and the opportunities that exist within this space for young women to reduce their risk, which taken together are referred to as the risk environment (Rhodes, 1997). In keeping with this risk environment approach, physical and social context (including social disorder, social networks, and social capital) are understood to interact to drive individual risk for HIV and the uptake of opportunities to reduce this risk (Rhodes, 2002, Rhodes, 2009, Tempalski and McQuie, 2009).
South African studies have demonstrated the connection between environment and social conditions and sexual risk behaviour among poor young women. For example, poverty and gender inequality have been identified as drivers of age-disparate and transactional sexual relationships in which young women find it difficult to negotiate condom use (Chapman et al., 2010, Gevers et al., 2012, Jewkes et al., 2010). In addition, HIV-related stigma within social networks, limits young women's use of sexual and reproductive health services and has an impact on how young women are treated within these services (Fatti et al., 2014, Lince-Deroche et al., 2015). These dynamics discourage young women's use of health services and the adoption of HIV preventive behaviours (Holt et al., 2012).
While these studies provided insight into the social and structural drivers of HIV risk among poor young women in general, they did not acknowledge the heterogeneity in HIV prevalence found among young South African women. In particular, young women who use alcohol and other drugs (AODs) are missing from policy discussions about how best to reduce the drivers of HIV incidence among young South African women. This is a critical omission because young women who use AODs are likely to be more at risk for HIV infection than young women who do not (Delaney-Moretlwe et al., 2015).
In South Africa, the link between AOD use and risk for HIV infection has been well established (Kalichman et al., 2007, Parry and Pithey, 2006). AOD use among young women is associated with multiple, syndemic risks for HIV (Pitpitan et al., 2013). AOD use impairs judgment and decision-making and this has been shown to lead to higher rates of inconsistent condom use (Kalichman et al., 2010, Parry and Pithey, 2006, Wechsberg et al., 2010). Further, women who use AODs report trading sex in exchange for AODs or money to buy AODs, or they may use AODs to cope with sex trading (Parry et al., 2008, Wechsberg et al., 2010, Wechsberg et al., 2006), which in itself increases risk of exposure to HIV (Dunkle et al., 2004, Parry et al., 2008). Young women who use AODs are also at increased risk for gender-based violence relative to young women who do not use AODs (Pitpitan et al., 2012, Rosenberg et al., 2015), which decreases the likelihood of condom use (Wechsberg et al., 2010).
These earlier findings suggest that efforts to reduce HIV incidence among young South African women are only likely to be effective if young women who use AODs are provided with comprehensive services—including access to sexual and reproductive health, mental health support, and AOD treatment services—that help them reduce these risks (Sawyer-Kurian et al., 2011, Wechsberg et al., 2010). Even though South Africa has a relatively well-developed AOD treatment system, comprising both residential and community-based outpatient services that offer a mix of evidence-based behavioural treatment approaches, less than 10% of poor women with AOD use disorders ever seek treatment, despite a high proportion desiring treatment (Myers, Kline, Doherty, Carney, & Wechsberg, 2014). Additionally, young women who use AODs rarely engage with other health services (Flisher et al., 2012, Luseno et al., 2010). While individual barriers to the uptake of these services have been identified (e.g., Myers et al., 2014), there is little understanding of how the risk environment of this marginalised population influences health service utilisation. This lack of information may hamper efforts to link these young women to health services, which ultimately may undermine efforts to achieve an HIV-free generation in South Africa.
As a first step to addressing this gap, we use qualitative data to explore how the risk environment of poor young women who use AODs in Cape Town informs access to and use of health services. In this study, we included the perspectives of young women who use AODs as well as the perspectives of service providers. The overall aim is to identify structural and contextual factors that should be targeted when developing interventions to improve linkage to health care for this most-at-risk population.
Section snippets
Study design and setting
As part of a larger study to adapt an evidence-based woman-focused HIV prevention intervention (Wechsberg et al., 2014) for a younger population, we conducted focus group discussions (FGDs) with young, AOD-using women from two peri-urban township communities in Cape Town, South Africa. More than 40% of residents in each of these communities are unemployed, with close to 70% having a monthly household income of less than ZAR 3000 (∼USD 300) (Statistics South Africa, 2013). We also conducted
Discussion
Although studies in other settings (Blankenship et al., 2015, Bobrova et al., 2006, Otiashvili et al., 2013, Strathdee et al., 2011) have shown that structural and contextual barriers have an impact on vulnerable women's use of AOD and health services, little is known about the risk environment of poor, young South African women who use AODs and how this informs health service utilisation. This study has identified important structural and contextual factors that need to be considered when
Acknowledgements
This study was supported by U.S. National Institute on Drug Abuse grant R01DA032061-04-S1 and U.S. National Institute of Child Health and Human Development grant R21 HD082866-01. We are grateful to all of the study participants and our study team in South Africa and the United States.
Conflict of interest statement: We wish to confirm that there are no known conflicts of interest associated with this publication and no financial support was received that could influence its outcome.
References (41)
- et al.
Barriers to accessing drug treatment in Russia: A qualitative study among injecting drug users in two cities
Drug and Alcohol Dependence
(2006) - et al.
Transactional sex among women in Soweto, South Africa: Prevalence, risk factors and association with HIV infection
Social Science & Medicine
(2004) - et al.
Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: A cohort study
Lancet
(2010) - et al.
Gender-based violence and HIV sexual risk behavior: Alcohol use and mental health problems as mediators among women in drinking venues, Cape Town
Social Science & Medicine
(2012) The ‘risk environment’: A framework for understanding and reducing drug-related harm
International Journal of Drug Policy
(2002)Risk environments and drug harms: A social science for harm reduction approach
International Journal of Drug Policy
(2009)- et al.
Drugscapes and the role of place and space in injection drug use-related HIV risk environments
International Journal of Drug Policy
(2009) - et al.
Structural Interventions for HIV prevention among women who use drugs: A global perspective
Journal of Acquired Immune Deficiency Syndrome
(2015) - et al.
Do behavioural differences help to explain variations in HIV prevalence in adolescents in sub-Saharan Africa?
Tropical Medicine and International Health
(2010) - et al.
Providing comprehensive health services for young key populations: Needs, barriers and gaps
Journal of the International AIDS Society
(2015)
Adolescent girls and young women: Key populations for HIV epidemic control
Journal of the International AIDS Society
Adolescent and young pregnant women at increased risk of mother-to-child transmission of HIV and poorer maternal and infant health outcomes: A cohort study at public facilities in the Nelson Mandela Bay Metropolitan district, Eastern Cape, South Africa
South African Medical Journal
Child and adolescent mental health in South Africa
Journal of Child and Adolescent Mental Health
‘I think it's about experiencing, like, life’: A qualitative exploration of contemporary adolescent intimate relationships in South Africa
Culture, Health & Sexuality
Targeting the SAVA (Substance abuse, violence and AIDS) syndemic among women and girls: A global review of epidemiology and integrated interventions
Journal of Acquired Immune Deficiency Syndrome
Assessment of service availability and health care workers’ opinions about young women's sexual and reproductive health in Soweto, South Africa
African Journal of Reproductive Health
HIV transmission risk behaviors among HIV seropositive sexually transmitted infection clinic patients in Cape Town, South Africa
European Journal of Public Health
Alcohol use and sexual risks for HIV/AIDS in sub-Saharan Africa: Systematic review of empirical findings
Prevention Science
‘Everything that I thought that they would be, they weren’t.’ Family systems as support and impediment to recovery
Social Science & Medicine
Accessing sexual and reproductive health information and services: A mixed methods study of young women's needs and experiences in Soweto, South Africa
African Journal of Reproductive Health
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