HIV This Week

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. 2008 Aug 7;337:a506. doi: 10.1136/bmj.a506

Jewkes et al aimed 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 was conducted in 70 villages (clusters) in the Eastern Cape province of South Africa. Participants were 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. The primary outcome measure was HIV incidence. Other outcomes being incidence of HSV-2, unwanted pregnancy, reported sexual practices, depression, and substance misuse. The authors found that 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. The authors concluded that 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. TRIAL REGISTRATION: Clinical Trials NCT00332878.

Editors’ note: Stepping Stones is a participatory HIV prevention programme that aims to be gender transformative, improving sexual health through building stronger, more gender equitable relationships. Developed for use in Uganda in 1995, it has been adapted for 17 settings, used in over 40 countries, translated into 13 languages, used with hundreds of thousands of individuals, but never has been evaluated using a randomised controlled trial design with biological outcomes. Although no impact on HIV was found, possibly due to sample size limitations, the reduced incidence of herpes simplex type 2 is significant and although women did not show much behaviour change, men reported significant behaviour change that likely reflects changing ideas of masculinity.