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Other outcomes: incidence of HSV-2, unwanted pregnancy, reported sexual practices, depression, and substance misuse.Results 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).
We conducted a trial to assess the impact of Stepping Stones on the incidence of HIV and HSV-2 and sexual practices among men and women in rural areas in the Eastern Cape province of South Africa.The form explained the procedures that would occur in some detail.After the group presentation we asked for confirmation that there was still general interest in participation and asked the young people to talk with their families before committing themselves.The project manager (MN) and field work coordinators in Mthatha identified and randomised the clusters and then enrolled participants.There was no blinding and for logistical reasons randomisation was done before village recruitment.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 this randomised trial we used a cluster design because the intervention is delivered to groups.
The setting was historically a subsistence farming region within a radius of 1.5 hours’ drive from the town of Mthatha, where contemporary households are primarily supported by contributions from family working elsewhere, grants, and pensions.
The incidence of herpes simplex type 2 virus (HSV-2) was lower in the group that had only a behavioural intervention but not in the group that had both this and treatment for sexually transmitted infections, and so the authors do not attribute the effect in the behavioural arm to success of their intervention.4 The failure to show a biological impact is a particularly important weakness as there are known limitations to the validity of self reported change in sexual behaviour, with a potential for interventions to bias reporting towards socially desirable behaviours, and because an effect on sexually transmitted infections is the ultimate objective of these interventions.5 7 8None of the intervention programmes previously evaluated was established and widely used before the research was conducted.
This is potentially an important weakness as development of interventions is an iterative process, and interventions are generally strengthened by being more extensively tested and adapted.9 In this respect Stepping Stones is a quite different intervention as it has been widely used for many years.10 It was originally developed for use in Uganda in 1995 and has been used in over 40 countries, adapted for 17 settings (including South Africa in 199811), translated into 13 languages, and used with hundreds of thousands of individuals.12 It is almost certainly the most widely used intervention of its kind in the world.
Interviewers administered questionnaires at baseline and 12 and 24 months and blood was tested for HIV and HSV-2.