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Substance use, sexual risk, and violence: HIV prevention intervention with sex workers in Pretoria
Global Health Sciences Literature Digest
Published January 20, 2009
Journal Article

Wechsberg WM, Luseno WK, Lam WK, Parry CD, Morojele NK. Substance use, sexual risk, and violence: HIV prevention intervention with sex workers in Pretoria. AIDS Behav 2006 Mar;10(2):131-7.


To pilot test whether an HIV prevention intervention designed for use with African-American women who abuse crack cocaine could be adapted for use with black South African sex workers who use cocaine and are at high risk for HIV and STIs

Study Design

A small randomized pilot trial of two U.S.-developed interventions to reduce substance use and HIV risk behaviors


Carried out in 2001 in Pretoria, South Africa, Gauteng, a province with high levels of cocaine and heroin use(1)


Included in the study were 93 black South African woman aged 18 years or older who had urine test results positive for cocaine or self-reported weekly cocaine use during the past 90 days; engaged in active sex work in the past 90 days; had multiple sex partners; and provided informed consent to participate in the study. A field staff worked with local outreach workers for targeted recruitment of women who were conducting sex work in day-rate hotels, apartments, and informal settlements or who were homeless and conducting sex work on the streets of Pretoria. Average age was 24 years, 73% were single, 75% completed secondary education, 96% reported sex work as a main source of income, 77% had been arrested at least once, and 67% reported having at least one current STI symptom. The follow-up rate was 86%.

At baseline, mean age at first paid sex was 16 years; 78% had not used birth control in their first encounter, and 29% reported that the sex was not consensual. Forty-two percent reported a condom breaking in the past week, and 98% had ever used a male condom. Fifty-nine percent had not used a condom with their boyfriend at last sex, 41% never used a condom with their boyfriend, and 41% reported that their boyfriend had other sexual partners. Forty-seven percent of participants reported being too high on drugs to negotiate condom use with paying clients on at least one occasion.

Baseline substance abuse was frequent: 72% reported daily cocaine use and 18% reported daily alcohol use during the past 30 days. Seventy-seven percent considered their substance abuse a problem, but only 26% knew about treatment, and only 7% had ever been in substance use treatment.

In terms of physical and sexual abuse, at baseline, 32% had been physically abused and 55% sexually abused before age 17. In the past year, 61% had been beaten by a boyfriend and 44% by a client, 19% had been cut by a client, and 39% had been robbed or not paid by a client. Twenty-seven percent had been raped by a client and 19% by a boyfriend; 15% had been gang raped.


Focus groups and community advisory board meetings informed the adaptation of an intervention designed for inner-city African-American women crack users to the context of the black South African women sex workers. The U.S. Standard Intervention was an adapted version (primarily language-based) of the revised NIDA Standard Intervention.(2) Cue cards were used to provide information on HIV; drug and sexual risks; risk-reduction methods, including proper use of male and female condoms; how to talk with a partner about safer sex practices; the HIV test; and preventing HIV. The interventionist also demonstrated proper condom use.

The second intervention, called the Woman-Focused Intervention, provided the same information as the Standard Intervention and, in addition, addressed HIV/AIDS issues facing women in South Africa, such as male dominance and attitudes towards women; multiple partners and sexual beliefs and values; safer sex practices with boyfriends; dispelling HIV/AIDS myths disclosed in focus groups; sexual violence; substance use; and cultural barriers to condom use. This intervention included a more personalized assessment of each woman's drug and sexual risks for goal planning and risk-reduction strategies through condom-use communication with sex partners. Women also were taught violence prevention tactics, such as ways to stay sober to assess the situation, communication techniques for different situations, and ways to exit a bad situation. Women also were shown how to actively seek community resources. The interventionist also demonstrated proper condom use with role-plays of rehearsed verbal assertiveness.

In both interventions, each participant was given a risk-reduction and toiletry kit and information on referral resources. The intervention comprised two private 1-hour sessions held within 2 weeks.

After completing an intake assessment, participants were randomly assigned to either the U.S. Standard Intervention or Woman-Focused Intervention. Approximately 1 month later, a follow-up questionnaire was administered.

Primary Outcomes

The primary outcome was pre- and post-intervention effects within each intervention group; specifically, changes in dichotomous variables, such as condom use and alcohol and crack cocaine use assessed using the McNemar test. Descriptive statistics were compiled on participants' demographic characteristics, sexual behavior, substance use, and experiences of violence.


Of the 93 women enrolled, 80 attended the 1-month follow-up. In terms of sexual risk, intervention effects at 1-month follow-up included an increase (23% to 33%) in the use of male condoms with their boyfriend in the past month in the Woman-Focused (WF) group. Condom use in the Standard (S) group stayed the same. Participant reports of always using a male condom with a client increased by 3% in the WF group and decreased by 10% in the S group. Women reporting using a male condom with a boyfriend at last sex increased from 28% to 55% in the WF group, but only by 4% in the S group. There was a large increase in the use of female condoms with boyfriends: from 3% to 48% in the WF group and 20% to 40% in the S group. Likewise, use of female condoms with clients in the past month increased from 12% to 68% in the WF group and from 13% to 61% in the S group. Alcohol or drug use or both during sex work in the last week decreased from 65% to 54% in the WF group and 58% to 53% in the S group. Using paired t-tests, participants in the WF group reported fewer STI symptoms at follow-up than did women in the S group (mean 0.64 vs. 1.07; effect size [d]= -0.43).

In terms of substance use, intervention effects at 1-month follow-up included a decrease in daily alcohol use in the WF group from 15% to 5% and in the S group from 18% to 10%. Reported daily cocaine use decreased from 64% to 33% in the WF group and from 75% to 40% in the S group.

Even at 1-month follow-up, violence continued to be a serious problem. Women reported being beaten by a boyfriend (22%) or by a client (32%), and 19% reported being robbed. Additionally, 14% reported being raped by a client and 5% by a boyfriend; 4% reported being raped by a gang. The WF group participants reported being victimized less often than did women in the S group (mean 4.5 vs. 6.3; d=-0.28).


The authors conclude that outreach is possible and that brief interventions can promote HIV and substance-use risk reduction; however, a larger study with extended follow-up is needed. The Woman-Focused Intervention was effective in increasing the use of male condoms with boyfriends, and both groups increased their use of the female condom. Violence remained a significant issue, and there was a clear need for greater involvement of partners and clients in HIV risk-reduction interventions.

Quality Rating

This was a well-designed pilot study that included lessons learned for future, larger studies. The intervention and questionnaires used at baseline and follow-up were discussed extensively in focus groups and with the community advisory board, demonstrating high-quality formative research and planning. Targeted sampling was used to obtain a sample of women eligible and representative of female cocaine users and sex workers in Pretoria, South Africa. As this was a small study with follow-up assessment after only 1 month, conclusions cannot be drawn about the persistence of the behavior changes observed. Outcomes also were measured by self-report and were subject to a possible response bias favoring the intervention. A longer intervention with a greater follow-up time, more participants, and more objective outcome measures is needed to demonstrate the intervention's effectiveness.

In Context

Few studies are available that demonstrate the effectiveness of behavior change and HIV prevention interventions for female cocaine-using sex workers in South Africa. Ensuring access to services and possibly providing alternative income-generating opportunities may be effective. Further long-term evaluation of behavior change interventions is necessary.

Programmatic Implications

Research procedures and interventions developed in the United States can be adapted for use in South Africa with the involvement of the target population and community advisory members.


  1. Parry CDH, Bhana A, Pluddemann A, et al. The South African Community Epidemiology Network on Drug Use (SACENDU): description, findings (1997-99) and policy implications. Addiction 2002;97:969-76.
  2. Wechsberg WM, Desmond D, Inciardi JA, Leukefeld CG, Cottler LB, Hoffman J. HIV prevention protocols: adaptation of evolving trends in drug abuse. J Psychoact Drug 1998;30(3):291-8.