The women of Virginia, a mining community in South Africa's Free State Province, call the project "Lesedi," or "We have seen the light." Once suspicious of the free diagnosis and treatment of sexually transmitted infections (STIs) the project offered -- and of its connection with HIV prevention -- the women now embrace it as their own.
And the women are not alone. In just three years, Lesedi has grown from a small pilot of an innovative intervention to a full-fledged project with strong financial and moral support from the public and private sectors. Partners in an ongoing effort to replicate the intervention first tested in Virginia in other South African mining communities include Harmony Gold Mining Company Ltd., Goldfields Ltd., Joel Mine, the local branch of the National Union of Miners, and the local, state and national health departments.
These partners on the Lesedi Steering Committee are working, for example, to expand the Lesedi Project's STI and HIV prevention services to more communities surrounding the mines of Harmony Gold Mining -- the company that collaborated with Family Health International (FHI) on the original intervention in 1997.
"This project has dramatically reduced sexually transmitted diseases and forms a key part of our overall HIV/AIDS strategy," noted Mr. Bernard Swanepoel, chief executive officer of Harmony Gold Mining Company Ltd.
Union leaders are also enthusiastic about the project. Sethoke Mahemu, chairperson of the Harmony branch of the National Union of Mineworkers, recalls that there was some initial resistance among workers until they experienced tangible improvements in their health and productivity, such as fewer days of work lost due to illness and fewer visits to the mine's medical stations.
"It has worked so perfectly that results can be seen by all," said Mahemu. "We as the Harmony branch support this project wholeheartedly."
First Partnership
With more than 40 percent of sub-Saharan Africa's HIV infections, the countries of southern Africa have some of the highest HIV prevalence rates (percentages of people tested who are infected at a given time) in the world. Rapid social and economic change, increasing urbanization, and reliance on migrant labor in the region disrupt social and family life and create conditions favorable for sexual transmission of HIV. These conditions also facilitate the rapid spread of other STIs -- many of them easily curable -- that cause additional suffering and make HIV transmission far more efficient.
Business owners and managers in the region are increasingly aware of the direct medical costs of this epidemic, as well as the larger indirect costs due to decreased productivity, disability, premature death and worker retraining. Managers in industries with large populations of migrant workers, such as gold mining in South Africa, are particularly alarmed by projections of high infection rates.
Therefore, when representatives of FHI's AIDS Control and Prevention (AIDSCAP) Project approached several mining companies in 1996 to propose collaboration in HIV prevention, they found some interest. Managers at Harmony Gold Mining Company Ltd., located near the city of Welkom in Free State Province, were most receptive.
Harmony's manager of health services was concerned about the increasing number of miners hospitalized for HIV-related illnesses. Through its medical stations and personnel departments, the company was already educating miners about the risks of HIV and other STIs and making condoms more accessible. It also had improved the management of STIs at the medical stations. Still, STI rates remained high, and Harmony's medical staff was discouraged by the apparently slow pace of behavior change.
Designing the Intervention
The collaboration between FHI and Harmony Gold Mining Company began in Virginia, a residential community that has grown up around three hostels that are home to 4,000 miners for about 11 months of the year. Most of the miners are migrant laborers from other parts of South Africa or neighboring countries. Faced with limited economic opportunities, many of the women of Virginia have sexual relations with the miners for money or material support.
As a first step in designing an intervention, FHI/AIDSCAP worked with Harmony staff to develop a situation analysis of STI and HIV transmission in the communities around the mines. Previous ethnographic research in nearby mining communities had shown that commercial sex was common and condom use reported by sex workers was low. While preventive and curative STI care was available to miners, sex workers had reported numerous problems in getting medical attention.
The analysis by Harmony and FHI suggested that most STI transmission takes place between miners and a smaller number of commercial or casual sex partners. Such encounters can be risky because HIV and STI transmission are high in populations where migrant workers live apart from their families. Most of the HIV transmission in the mining communities is facilitated by the presence of other common, curable STIs.
The analysis also showed that miners had access to information, condoms and STI treatment, but underestimated the risk of HIV infection. The women living around the mines, on the other hand, were at high risk of acquiring and transmitting STIs but had poor access to preventive and curative services. Often even basic health services were not available.
To refine the analysis and gather information needed to design an appropriate intervention, project staff mapped the meeting places for high-risk sexual encounters in the community. Interviews and meetings with women and men in bars, shebeens (informal bars), taxi ranks and other meeting places helped clarify how community-based STI services could be organized to best reach those who needed them.
The situation analysis suggested that control of STI and HIV transmission in the mining communities would depend on extending effective services to women at highest risk of infection. AIDSCAP and the Sexually Transmitted Disease Reference Centre at the South African Institute for Medical Research in Johannesburg worked with Harmony Hospital to design a pilot intervention to improve access to STI preventive and curative services for these women.
The recommended approach to STI diagnosis and treatment -- syndromic management -- was adopted for high-risk women with symptoms. But syndromic management is based on a patient's symptoms and clinical signs of infection, rather than laboratory diagnosis. Given the high prevalence of asymptomatic STIs among women in the mining communities, reliance on syndromic management alone would have resulted in many untreated infections.
Instead, project designers decided STI prevalence levels were high enough to justify periodic presumptive treatment, or regular treatment based on the likelihood of infection rather than clinical diagnosis. In fact, baseline data from the pilot project showed that half of the women had one or more curable STIs on the first visit to the new clinic.
At this mobile clinic, a nurse provided women with clinical services, including monthly presumptive treatment -- a single dose of the antibiotic azithromycin -- for several of the common curable STIs in the community. The services offered also included condoms and information about HIV and other STIs.
At the beginning of the pilot intervention, two outreach workers promoted clinic attendance by talking to women in the different meeting places and handing out referral cards. Later, to encourage women to make follow-up visits, six regular clinic attendees were recruited and trained as peer educators. Through one-on-one conversations and group meetings, these women explained the services available at the clinic and built community trust and involvement in the program.
Evidence of Impact
Mining companies, like other businesses, generally do not provide healthcare services for people other than employees and their dependents. It was therefore essential to demonstrate to mine management that a community intervention was in the immediate interest of the company. To do so, FHI and its partners developed a protocol to evaluate the impact of the intervention not only on the women served, but also on the miners living in the area.
The project collected information on STIs in three ways. STI rates were measured among the women coming for services at each visit to justify that they were indeed in need of treatment services. Among the miners, STI prevalence was measured in samples of miners presenting for routine examinations before and after the implementation of the community intervention. In addition, the mines tracked rates of symptomatic STIs seen at mine medical stations at varying distances from the intervention.
Significant decreases in STI rates were documented by each of these methods. Among women using the service, the prevalence of the most common curable STIs dropped by as much as 85 percent in nine months. Screening during routine annual examinations revealed a 43 percent lower rate of gonorrhea or chlamydial infection and 78 percent fewer genital ulcers among miners. And the results of the monitoring at mine medical stations suggest that proximity to the intervention site reduced a miner's risk of acquiring an STI.
Although data on HIV were not available, estimates of how these reductions in STIs affected HIV transmission were developed using FHI's AVERT model. This probability-based computer model estimated that providing periodic presumptive STI treatment and peer education to 400 women had averted 40 HIV infections among the women and 195 HIV infections among the larger group of miners.
The AVERT estimates were also used to develop simple cost-benefit calculations comparing the cost of the intervention to the potential savings in medical costs due to averted HIV infections. The result -- an estimated savings of $US 539,630 to the mining company -- suggests that the intervention is highly cost-effective.
Building Local Partnerships
It was essential to disseminate these evaluation results quickly. The pilot project had begun near the end of FHI's AIDSCAP Project, which was funded by the U.S. Agency for International Development (USAID) from 1991 to 1997, and support was ensured for only nine months.
Preliminary project results were first presented to the Harmony Mine management in June 1997, the ninth month of the pilot project. Presenters emphasized the impact of the intervention on STI rates among miners and the low cost of project implementation compared to estimates of averted medical costs.
Harmony's management reacted favorably to the presentation. In fact, they argued that the cost savings were underestimated, citing indirect costs of HIV to the company, such as reduced productivity, retraining, repatriation and death benefits.
After the presentation, the managers agreed to fund continued operation of the mobile clinic for women during the immediate post-AIDSCAP period. They also requested that a plan be developed to expand the community intervention to areas around their other mines in Free State Province, and urged working in partnership with the Department of Health and other mining companies to strengthen STI and HIV prevention efforts.
National and provincial health department representatives and local health authorities expressed interest in the intervention and its results. They were particularly impressed by the commitment of the mine management to support the project. The national Department of Health pledged support for evaluation, and provincial funds were committed to strengthen peer education efforts. Local health authorities agreed to work closely with the project nurse to facilitate referrals to family planning and other health services for women seen at the clinic. All agreed to participate in meetings to guide project activities.
After the Lesedi results were presented to other mining companies operating in the area, two other mines were persuaded to support expansion of community services for women at high risk of HIV and other STIs in areas around their mines.
The first meeting of interested collaborators was held at Harmony in September 1997. Representatives from the three mines (Harmony, Goldfields Ltd. and Joel Mine), the national, provincial and local departments of health, the South African Institute for Medical Research and USAID developed an outline for collaboration and expansion of the intervention that would soon lead to more formal support.
The national Department of Health played an important facilitative role during the initial post-AIDSCAP period. In addition to helping the project secure funding from the European Union for staffing and other immediate needs, visible support from the national level helped overcome resistance to what some local opponents saw as an unorthodox approach. Health department intervention was particularly effective in assisting with regulatory issues regarding prescription practices and licensing of the mobile clinic.
In collaboration with both industry and health authorities, the Lesedi Project has been able to successfully build a platform of support for an expanding intervention. In fact, Lesedi's results are changing the way the mining industry approaches HIV prevention. In addition to providing condoms and improving STI services for their employees, companies are increasingly seeing the logic of supporting community interventions. In the Free State, other mining companies have pledged support to replicate the Lesedi intervention around the nearby mining town of Welkom. Closer to Johannesburg, two mobile clinic teams recently began providing services to women at high risk of STI in the town of Carletonville, one of the largest mining areas in the region.
Lessons from Lesedi
In three years of implementation, Lesedi's approach to community-based STI prevention and treatment for women at high risk of infection has developed from a small pilot project to a self-sustaining intervention that is being replicated in mining communities and other areas with similar transmission dynamics. Several elements have contributed to this success.
First, a careful analysis of the situation guided the initial response. Its findings suggested that a similarly comprehensive approach was required to reduce STIs. This meant identifying and involving in the solution marginalized groups (sex workers and other women at risk in the community) who had previously been neglected.
From the beginning, the project sought to include all interested parties in order to build a broad base of support. For example, the support of the unions was critical. Union leaders explained the objectives of the intervention to the miners and obtained their cooperation and support for the examinations that were an important component of the evaluation. Union support also helped the project maintain a positive image and prevent discrimination towards women using the services.
The project maintained close communication with the departments of health at several levels. Briefings with local health authorities helped keep them informed and made it easier to coordinate referrals. Provincial and national health department representatives were consulted early and played important roles in resolving regulatory issues, identifying sources of support and facilitating the exchange of information among mining projects.
Participatory planning and sound financial controls became increasingly important as the project expanded and more stakeholders became involved. A planning committee now meets regularly, and meeting minutes are circulated to all committee members. Annual project and financial reports ensure transparency and accountability.
Because the pilot intervention employed new approaches, FHI and its partners took care to collect the data that would be needed to evaluate it and interest potential stakeholders. "Process indicators," such as numbers of peer educator referrals and clinic attendance figures, served as measures of the operational efficiency of different aspects of the intervention. Outcome measures, including reported condom use and STI rates among women receiving project services, were used to document the immediate benefits of the intervention to its direct beneficiaries.
Perhaps most important, additional effort was made to demonstrate public health impact by collecting data on STI rates among miners. This last element, supplemented by modeled estimates of averted HIV infections and cost-benefit analysis, was probably most instrumental in ensuring continued support and expansion of the intervention.
-- Tony De Coito, Stori Ralepeli and Richard Steen
Tony De Coito is manager of health services for Harmony Mining Company, Ltd. Stori Ralepeli is the STI project manager and a professional nurse in charge of the Lesedi clinical services. Both currently serve as co-chairpersons of the Lesedi Steering Committee. Richard Steen works as an international STI advisor for FHI.
References
- R Steen, B Vuylsteke, T De Coito, S Ralepeli, et al. Evidence of declining STD prevalence in a South African mining community following a core group intervention. Sexually Transmitted Diseases January 2000, 21(7):1-11.
- T Rehle, T Saidel, S Hassig, P Bouey, E Gaillard and D Sokal. Avert: A user-friendly model to estimate the impact of HIV/sexually transmitted disease prevention interventions in HIV transmission. AIDS 1998, 12(suppl. 2):S27-S35.
