1. Stepping Stones and Creating Futures Gender and Health Unit, MRC Project EmpowerHEARD, UKZNUniversity of Pretoria Rachel JewkesMpume MbathaAndy GibbsMilly Mushinga Nwabisa Jama- Shai Laura WashingtonAlison Misselhorn Yandisa Sikweyiya Ntokozo MadlalaSamantha Willan Funded by: SIDA, the Joint Gender Fund and the MRC (South Africa) Project Start Date: January 2011 Project End Date: August 2013

2. Session Objectives This session has three main objectives: To enable participants to understand the importance of tackling gender inequalities and poverty simultaneous To share initial findings of the Stepping Stones/Creating Futures intervention To provide participants with the experience of a livelihoods intervention

3. Outline of this session Why tackle gender inequalities and poverty for HIV prevention? Power Walk (30 minutes) Stepping Stones and Creating Futures - presentation (30 minutes) Creating Futures - experience (30 minutes)

4. Rationale Assumption: Gender inequalities intersect with livelihood insecurity to increase HIV risk behaviours and gender-based violence: Women – poverty linked to IPV, challenges negotiating condom use, transactional sex, inability to exit violent relationships (Hunter, 2010; Jewkes & Morrell, 2012) Men – livelihood insecurity linked to perpetration of violence, HIV prevalence, MCPs, alcohol use (Hunter, 2010) Therefore: transform gender relationships and build livelihoods…

5. Previous evaluations of similar interventions InterventionApproachSettingOutcomes IMAGEMicrofinance and gender transformation South Africa: Rural, av. age 41, women Women’s experience of IPV reduced by 55% SHAZ!Gender transformation & vocational skills Zimbabwe: urban, adolescent, women Increase in HIV-related knowledge and relationship power, no significant change in current sexual activity or condom use at last sex Micro- enterprise services for sex workers Microfinance, peer education Kenya: urban, female sex workers 45% reported leaving sex work. These results were highly age dependent with older women reporting better outcomes TRYMicrofinance, educational topics Kenya: urban, adolescent women Increased ability to insist on condom use

6. Informal settlements and HIV Informal settlements are a key HIV issue: 28% of people living with HIV/AIDS in southern and eastern Africa live in 14; approximately 15% of the global epidemic (van Renterghem & Jackson, 2009) In South Africa, 29.1% of the total estimated number of new HIV infections are found in urban informal settlements, even though only 8.7% of South Africans older than 2 years live in these areas (Rehle et al., 2007) Few scientific evaluations of interventions in these communities (Gibbs et al., 2012)

7. Stepping Stones Used globally since 1995 – aims to achieve HIV prevention through greater gender equality Two year evaluation (by MRC): Reduced HSV2 new infections by 33% in men and women Less risky drinking – men Reduced IPV – men Less transactional sex – women and men (Jewkes et al., 2008) 10 session intervention

8. Creating Futures: supporting young people in building their livelihoods Jointly created by the three partner organisations It seeks to encourage reflection and action among young people on their livelihoods through participatory activities Ten sessions

9. Builds on a livelihoods framework: Human capital (education) Social capital (networks, relationships) Physical capital (housing) Financial capital (savings, work) Natural capital (land, rivers) Creating Futures encourages young people to reflect on their activities and decisions within this broad framework Creating Futures

10. Process to develop manual 1.Workshop with a broad set of stakeholders early in 2011 to explore the context 2.Partnered with an ‘implementing’, grass roots organisation 3.Literature scan- livelihoods and curriculum theory 4.Log-frame development 5.Expert review 6.Manual development 7.2x pre-tests Creating Futures

11. Delivering Stepping Stones and Creating Futures Recruited 233 young people (110 men, 123 women) with an average age of 21.7 years All from informal settlements around Durban Two-thirds of women had given birth to a child, compared to one third of men who had fathered a child Only 45% of men and 24% of women had finished high school Men and women reported rates of intimate partner violence (physical and sexual) in the past 12 months of 40%, compared to a national average of 13%

12. Design of study Combined Stepping Stones & Creating Futures Intervention (20 sessions) Quantitative survey (233), FGDs – in- depth interviews Quantitative survey In-depth interviews 0 Months 6 Months 12 Months Quantitative survey (206) 2 weeks Quantitative survey (221 – 95% followed- up) In-depth interviews

13. Implementing the intervention May – August 2012 Retention/attendance: Attended 1 session: 183 (13% drop out) Attendance – 50% overall Taxi strikes Highly mobile population: CT, EC, Jo’burg, rural areas Boyfriends controlling girlfriends Sbu facilitates a discussion on a body map participants have drawn

14. Outcomes: Warning! 1.Not final results – April 2013 2.No significance tests done 3.Instability of scales: reporting where we have ‘strong’ evidence of change/ correlate with Stepping Stones outcomes 4.Small scale study with no control Casper facilitating a discussion on women’s expectations of men

15. Improving livelihoods Men and women increased mean income in past month: Men from R411 (US$45) to R713 ($77 a 73% increase) Women R174 ($18) to R255 ($28 a 47% increase) Job seeking only changed among women: Looking for jobs in newspapers more in the past three months, from 45% to 66% Sent off a job application in past 3 months – increased by 11% Stealing in the last month because hungry: 22% decline among men, 18% decline among women

16. Improved thinking around livelihoods Improved navigation of work settings: Young man: “Before I used to do things recklessly, drink alcohol and come back home around 12am or 1am while I would be going to work that morning, and I would go to work and get warnings, but Project Empower showed me how to do things” Improvement in savings Male participant – focus group: What I have learnt is to stick to my budget and also make a list and stick to those things that are in the list and not spend money on unimportant things.

17. Critical thinking about gender relationships INTERVIEWER: According to you, what makes a good woman? NOMZAMO (Female): Women who would be independent, they would not expect to be controlled by men, firstly. They would not allow a man to control them. They must know that they also have rights and have to fight for them. She must work for herself and not expect to be given things Male participants acting out a role play during Stepping Stones Critical thinking about relationships is a pre- condition for acting in new ways

18. Greater focus on main partner Interviewer: let’s talk about the experience you had with the program like what made you get involved with the project? Mandla (male): this programme has helped me a lot like workwise I’m holding on to it, and the person I am dating I have committed myself to her and other things are progressive and my child is growing well Percentage men who reported that their last sexual act was with main partner: 50% at baseline to 62% at follow up, a 23% increase (potential decrease in overlapping/concurrent relationships) Percentage women reporting satisfactory sexual relationship with main partner increased (up 12%)

19. Transactional sex Men’s participation in transactional sex in the past three months from 24% to 18% (a 23% decline) Women’s participation in transactional sex in the past three months increased – same as Stepping Stones. But, there was a 23% reduction in women reporting that their last experience of transactional sex was conditional on the exchange

20. Mental Health Severe depression amongst men: 50% down to 37% (74% decline) Suicidal thoughts past 4 weeks: 28% decline among men No impact on mental health among women

21. Substance use Vusi (Male): You see we sit down [my girlfriend and I] and discuss things together, like maybe let’s for an example like when I used to drink… Interviewer: So have you stopped drinking? Vusi: Yes. Interviewer: Or you have taken a break? Vusi: No I have stopped, but they [friends] try to get me to drink again but they never are successful at it (laughing) no they fail! Arguing with a partner about alcohol use in the past three months also declined among men (35%) and women (27%) Women’s use of drugs: declined from 17% to 8%

22. Outcomes Summary Short-term positive trends: Strengthening livelihoods (more working, more earnings, women ‘trying’ more) Gender relationships changing – parallel Stepping Stones (esp. focus on main partner) Wider health benefits – parallel Stepping Stones (reduction in substance abuse, decrease mental health issues) Sustaining these into the future - critical