Jewkes R, Nduna M, Levin J, Jama N, Dunkle K, Puren A, Duvvury N. Impact of Stepping Stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial. BMJ 337:a506

Gender and Health Research Unit, Medical Research Council, Private Bag X385, Pretoria 0001, South Africa.
BMJ (online) (Impact Factor: 17.45). 02/2008; 337(7666):a506. DOI: 10.1136/bmj.a506
Source: PubMed


To assess the impact of Stepping Stones, a HIV prevention programme, on incidence of HIV and herpes simplex type 2 (HSV-2) and sexual behaviour.
Cluster randomised controlled trial.
70 villages (clusters) in the Eastern Cape province of South Africa.
1360 men and 1416 women aged 15-26 years, who were mostly attending schools.
Stepping Stones, a 50 hour programme, aims to improve sexual health by using participatory learning approaches to build knowledge, risk awareness, and communication skills and to stimulate critical reflection. Villages were randomised to receive either this or a three hour intervention on HIV and safer sex. Interviewers administered questionnaires at baseline and 12 and 24 months and blood was tested for HIV and HSV-2.
Primary outcome measure: incidence of HIV. Other outcomes: incidence of HSV-2, unwanted pregnancy, reported sexual practices, depression, and substance misuse.
There was no evidence that Stepping Stones lowered the incidence of HIV (adjusted incidence rate ratio 0.95, 95% confidence interval 0.67 to 1.35). The programme was associated with a reduction of about 33% in the incidence of HSV-2 (0.67, 0.46 to 0.97; P=0.036)-that is, Stepping Stones reduced the number of new HSV-2 infections over a two year period by 34.9 (1.6 to 68.2) per 1000 people exposed. Stepping Stones significantly improved a number of reported risk behaviours in men, with a lower proportion of men reporting perpetration of intimate partner violence across two years of follow-up and less transactional sex and problem drinking at 12 months. In women desired behaviour changes were not reported and those in the Stepping Stones programme reported more transactional sex at 12 months.
Stepping Stones did not reduce incidence of HIV but had an impact on several risk factors for HIV-notably, HSV-2 and perpetration of intimate partner violence.
Clinical Trials NCT00332878.

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    • "Although a Cochrane review found that educational and contraceptive provision programs in general do prevent pregnancy, data came primarily from high-income countries [9]. One cluster randomized trial in South Africa randomized participants to a 50-hour participatory learning intervention or a short didactic program [10] "
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    ABSTRACT: The need to prevent early pregnancy and HIV among adolescent girls in Sub-Saharan Africa has been recognized increasingly over recent years. Although extensive work has been done to determine appropriate interventions for girls in high-income countries, very little evidence is available to guide programmatic interventions in Sub-Saharan Africa. The available evidence has been equivocal regarding improved outcomes. While knowledge and self-reported behaviors frequently change with interventions, including those performed at the community level, educational programs, and direct contraceptive provision, downstream outcomes rarely reflect a significant effect of the interventions; however, provision of financial or other interventions to incentivize continued school enrollment are a promising development. We suggest directions for future research to fill this critical gap in the literature.
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    • "However, a more cautious analysis of the types of change that are secured by such interventions suggests that men's strides towards gender equity are at best incremental (Gibbs et al. 2014; Jewkes, Wood, and Duvvury 2010). Some interventions with men have shown an ability to reduce perpetration of violence, but the relationship between this and change in hegemonic masculinity is uncertain because the relationship between violence and hegemonic masculinity is itself contested (Jewkes et al. 2008). This observation does not mean that revolutionary change cannot ever be achieved, but it does suggest that in order to do so, interventions supporting structural and individual change need to be substantially different, and perhaps delivered over a much longer time frame than is currently common practice. "
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    • "Specific strategies that hold potential for reducing and/or ameliorating violence against women include economic, social, and policy approaches to improving gender equality; challenging gender-based social norms by redefining negative masculine norms; schoolbased prevention activities with children and youth; strengthening the social safety net; and reducing poverty and preventing incidents of child abuse (WHO, 2009). Examples of effective primary prevention programs that are predicated on promoting gender equitable social norms and fostering attitudes that are intolerant to violence against women include the Safe Dates program in the United States (Foshee et al., 2004) and the Stepping Stones program in South Africa (Jewkes et al., 2008). "
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