"Wising Up" to Alcohol-Related HIV Risk, Cape Town, South Africa

This 12-page case study, published by AIDSTAR-One, looks at the South African health communication programme Phaphama (which means "wise up" in Zulu and other South African languages), which was designed to reduce alcohol-related sexual risk among patients with sexually transmitted infections (STIs) seeking care at a primary health care clinic. Phaphama ran between 2005 and 2009, and combined counselling to reduce hazardous drinking with HIV risk-reduction counselling in a single 60-minute session. According to the authors, the approach has led to documented successes in changing behaviours that are notoriously resistant to change.

The case study explains that the overall goals of the programme were to: reduce the number of sexual partners and the number of unprotected sex acts; reduce the frequency of alcohol use before sex; and increase knowledge about HIV, including how to prevent transmission. Other goals included to: reduce AIDS-related stigma; increase personal intentions to reduce HIV risk behaviours; increase a personal sense of confidence that one can reduce HIV sexual risk behaviours; and reduce alcohol outcome expectancy (i.e. reducing the belief that one is a better sex partner after drinking).

During counselling sessions, clients received personalised information about how their drinking behaviour could lead to risky sex and got help from the counsellor to develop an action plan for reducing those risks. The session also addressed the intersection of alcohol use and HIV risk. The report outlines how clients were assessed for participation in the programme, and what a typical counselling session looked like.

An evaluation of the programme showed a 65% reduction in unprotected sex for Phaphama participants, who showed significantly more risk reduction than those in the comparison group. Authors say these reductions were sustained over a six-month period. In the three months following participation in the programme, alcohol use before sex was also significantly lower for those who had received the alcohol-HIV counselling. However, this was not sustained after six months. The authors say that this indicates a need for more intensive alcohol risk-reduction intervention components and maintenance intervention strategies.

The report includes several key areas of strength for the programme. The authors say that Phaphama worked well because it was evidence-informed and highly relevant. The personalised approach, which was appreciated by both clients and counsellors, also helped make the programme successful. According to the authors, Phaphama was very specific in the way it reached its audience - i.e. it was designed to address HIV prevention needs of a most-at-risk population. It also capitalised on existing health care infrastructure.

The authors say there were some challenges in implementing the programme as well. Creating demand for it and expanding the reach were not always easy. Many people invited to participate were either not interested, did not qualify, or were unable to devote the time to a 60-minute counselling session. The programme also needs to look at developing better strategies for serving women. The authors say that programme organisers found a lack of community-based support for sustaining reductions in risk over time, as well as lack of services for treatment of alcohol dependency.

However, the authors recommend using high-intensity, individualised programmes like Phaphama for most-at-risk individuals seeking help. They also recommend incorporating counselling on alcohol into existing HIV prevention counselling services, and ensuring that programmes are equally accessible to women and men who are at risk.

Future interventions could include:

• providing intensive counselling services for most-at-risk populations in combination with promoting alternative income generation for women who engage in transactional sex;
• providing alternative recreation opportunities for people living in low-income and high-density urban neighbourhoods so that drinking is not the only way to relieve boredom;
• enforcing liquor licensing laws to reduce the number of alcohol retail outlets and ensure that those that are licensed sell and serve alcohol responsibly; and
• creating mass media campaigns to broadcast messages about how to be healthier by moderating alcohol use.