Testing the Efficacy of Safe South Africa

Adolescence presents an ideal developmental transition period for an integrated intervention targeting prevention of HIV risk behaviors and intimate partner violence (IPV), including sexual violence. Adolescent boys in particular are at high risk for HIV and perpetration of IPV. Yet, few behavioral interventions integrate HIV-IPV prevention and are tailored for the unique developmental needs of adolescent boys. In this study, investigators build on previous scientific work that demonstrated the acceptability and feasibility of Safe South Africa, an integrated HIV-IPV intervention that uses a developmentally- and gender-tailored approach grounded in social norms theory to prevent adolescent HIV risk behavior and IPV. Investigators will conduct the work in South Africa, a country with the largest HIV epidemic and some of the highest rates of IPV in the world. The investigative team propose the following specific aims: (1) Tailoring Safe South Africa intervention content to address the unique behavioral and social norms data that drives HIV and IPV behaviors among boys in their socioecological environments. (2) Testing the efficacy of the Safe South Africa intervention in preventing HIV/STIs and reducing IPV frequency among N=836 adolescent boys (ages 15- 17), with the scientific team's working hypothesis that the intervention, relative to the usual care condition, will show (a) lower incidence of any STI (including HIV); and (b) reductions in IPV perpetration frequency and decreased endorsement of IPV supportive attitudes. (3) Identifying barriers and facilitators to implementing Safe South Africa within a school setting to provide data for future dissemination (presuming Safe South Africa is efficacious). Investigators will examine processes critical to future dissemination through (a) fidelity data examining adherence to core active components of the standardized intervention manual guiding consistent delivery of the intervention; and (b) qualitative data on the experience during and post-implementation from adolescents and stakeholders using N=20 in-depth interviews with each group.

• Safe South Africa (Behavioral): The Safe South Africa intervention is a developmentally-tailored intervention for adolescent boys, designed to reduce actual or intended HIV risk behaviors, actual or intended IPV perpetration frequency, and endorsement of IPV supportive attitudes. This intervention comprises 2-hour sessions, held once a week for a total of two weeks. The intervention also includes take-home activities to deepen behavioral engagement with received sessions and to "prime the pump" for up-coming sessions. Part 2 involves behavioral practice, including bystander intervention techniques.

Primary outcomes

• Reduction in incidence of HIV and or Chlamydia and or Gonorrhoeae [12 months]: Biologically verified Chlamydia trachomatis and/or Neisseria gonorrhoeae and/or HIV are measured as incident infections, defined as the number of participants in the sample who newly acquire HIV and/or Chlamydia and/or Gonorrhoeae as compared to the prior timepoint (this compares 12 month data to baseline). Chlamydia and Gonorrhoeae will be measured using urine sample using an assay (Discharge Multiplex PCR). HIV samples will be captured using a sterile single-person pricking tool is used to create a five dried blood spots card. Samples are tested using a 4th generation assay (Biorad Genscreen ULTRA HIV Ag-Ab assay).
• Reduction in acts of intimate partner violence [12 months]: For those who have engaged in intimate touching, self-reported data on the number of completed acts of forced touching, oral sex, anal sex, and vaginal sex, as well as attempted acts of forced oral, anal, and vaginal sex are collecting using the Sexual Experiences Survey (SES) Short Form Perpetration (SES-SFP) is a survey tool developed by Mary P. Koss (Koss, M. P., Abbey, A., Campbell, R., Cook, S., Norris, J., Testa, M., Ullman, S., West, C., \& White, J. (2007). Revising the SES: A Collaborative Process to Improve Assessment of Sexual Aggression and Victimization. Psychology of Women Quarterly, 31(4), 357-370. https://doi.org/10.1111/j.1471-6402.2007.00385.x). The number of participants who have engaged in one or more acts of completed or attempted forced touching are reported at the 12 month timepoint, as compared to prior timepoints.
• Lower proportion of those who have reduced endorsement of intimate partner violence supportive attitudes [12 months]: For those who have engaged in intimate touching, self-reported data on endorsement of IPV supportive attitudes will be measured using the Rape Myth Acceptance Scale. At 12 months, we will compare the proportion of individuals who will lower their Rape Myth Acceptance (RMA) score between baseline and twelve months. The Rape Myth Acceptance Scale is: • Payne DL, Lonsway KA, Fitzgerald LF. Rape myth acceptance: Exploration of its structure and its measurement using the Illinois Rape Myth Acceptance Scale. Journal of Research in Personality 1999;33:27-68.

Sex: Male, ages: 15 Years to 17 Years, accepts healthy volunteers

Inclusion Criteria:

* identification as boys
* ages 15-17 years
* enrolled at public high schools in South Africa situated in communities with high rates of HIV and violence

Exclusion Criteria:

* does not have written parental consent
* does not have written assent

• Study Protocol and Statistical Analysis Plan (PDF, 2024-12-17)

• Caroline Kuo, Principal investigator, American University and Brown University