Impact of Stepping Stones on Incidence of HIV and HSV-2 and Sexual Behaviour in Rural South Africa: Cluster Randomised Controlled Trial

This report, published by BMJ, an online medical journal of the British Medical Association, aims to assess the impact of Stepping Stones, a South African HIV prevention programme, on incidence of HIV and herpes simplex type 2 (HSV-2) and sexual behaviour. Stepping Stones is a 50-hour programme designed to improve sexual health by using participatory learning approaches including role play and drama to build knowledge, risk awareness, and communication skills, and to stimulate critical reflection on issues related to sexual health and behaviour. According to the study, participation in the Stepping Stones programme in South Africa did not reduce the incidence of HIV infection, but was associated with a reduced incidence of HSV-2.

The study involved testing participants for HIV at the outset, and at 24 months, after participation in the Stepping Stones programme. In addition, questionnaires were given at 12 and 24 months. According to this report, there was no evidence of any desired behaviour change in women, though men reported less transactional sex at 12 months, less perpetration of intimate partner violence, less problem drinking at 12 months, and less drug misuse at 24 months. There was a suggestion of change in several other outcomes in men, including fewer partners, less likelihood of casual partners, and less rape at 12 months, and less depression at 24 months.

The study notes that possible explanations for the lack of demonstrated impact on women's behavioural outcomes could be under-reporting of sexual activity at baseline, and the fact that because of unequal gender relations, women have less power to change their sexual behaviour. Also, the programme may have influenced unmeasured behaviour changes, or choices of partners.

The study also found that there was more transactional sex and unwanted pregnancies among women, leading to the recommendation that facilitators of the Stepping Stones programme should take care when discussing transactional sex, being sure to emphasise the negative impacts while retaining a neutral moral stance.

The study concludes that, although some would argue that Stepping Stones did not work because it failed to affect the incidence of HIV, it had several other positive outcomes - for example, reduction of HSV-2 and intimate partner violence, both of which are recognised risk factors for HIV.