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Impact of Stepping Stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial

BMJ 2008; 337 doi: (Published 07 August 2008) Cite this as: BMJ 2008;337:a506
  1. Rachel Jewkes, director12,
  2. M Nduna, lecturer3,
  3. J Levin, chief statistician 4,
  4. N Jama, director1,
  5. K Dunkle, assistant professor (research)5,
  6. A Puren, deputy director6,
  7. N Duvvury, director7
  1. 1Gender and Health Research Unit, Medical Research Council, Private Bag X385, Pretoria 0001, South Africa
  2. 2School of Public Health, University of the Witwatersrand, South Africa
  3. 3Department of Psychology, University of the Witwatersrand, South Africa
  4. 4Biostatistics Unit, Medical Research Council, Pretoria, South Africa
  5. 5Behavioral Sciences and Health Education, Emory University, Atlanta, GA, USA
  6. 6Virology, National Institute for Communicable Disease, Sandringham, South Africa
  7. 7Gender Violence and Rights Team, International Centre for Research on Women, Washington DC, USA
  1. Correspondence to: R Jewkes rjewkes{at}
  • Accepted 28 May 2008


Objective To assess the impact of Stepping Stones, a HIV prevention programme, on incidence of HIV and herpes simplex type 2 (HSV-2) and sexual behaviour.

Design Cluster randomised controlled trial.

Setting 70 villages (clusters) in the Eastern Cape province of South Africa.

Participants 1360 men and 1416 women aged 15-26 years, who were mostly attending schools.

Intervention Stepping Stones, a 50 hour programme, aims to improve sexual health by using participatory learning approaches to build knowledge, risk awareness, and communication skills and to stimulate critical reflection. Villages were randomised to receive either this or a three hour intervention on HIV and safer sex. Interviewers administered questionnaires at baseline and 12 and 24 months and blood was tested for HIV and HSV-2.

Main outcome measures Primary outcome measure: incidence of HIV. Other outcomes: incidence of HSV-2, unwanted pregnancy, reported sexual practices, depression, and substance misuse.

Results There was no evidence that Stepping Stones lowered the incidence of HIV (adjusted incidence rate ratio 0.95, 95% confidence interval 0.67 to 1.35). The programme was associated with a reduction of about 33% in the incidence of HSV-2 (0.67, 0.46 to 0.97; P=0.036)—that is, Stepping Stones reduced the number of new HSV-2 infections over a two year period by 34.9 (1.6 to 68.2) per 1000 people exposed. Stepping Stones significantly improved a number of reported risk behaviours in men, with a lower proportion of men reporting perpetration of intimate partner violence across two years of follow-up and less transactional sex and problem drinking at 12 months. In women desired behaviour changes were not reported and those in the Stepping Stones programme reported more transactional sex at 12 months.

Conclusion Stepping Stones did not reduce incidence of HIV but had an impact on several risk factors for HIV—notably, HSV-2 and perpetration of intimate partner violence.

Trial Registration Clinical Trials NCT00332878.


  • We thank the Planned Parenthood Association of South Africa Eastern Cape Branch, our partner in the study intervention; the National Institute for Communicable Diseases for quality control, testing, and storage of specimens; Nelisiwe Khuzwayo (community coordinator); Leslie Setheni, Veliswa Gobinduku, Busiswa Mketo, Yandisa Sikweyiya, Mthokozisi Madiya, Bongwekazi Rapiya, Sanele Mdlungu, Ayanda Mxekezo, Lungelo Mdekazi, Nocawe Mxinwa, Andiswa Njengele, Mvuyo Mayisela, Philiswa Bango, Nobapostile Malu, Lizo Tshona, Khanyisile Bakan, Linda Shute, Lindiwe Farlane, Siya Kave, Bantu Waka, Zoleka Mbange (field nurses and field workers); Bomkazi Mnombeli, Engela Gerber, Alta Hansen (data management, data entry, and secretarial support); Daniel Kayongo, UNITRA (advice on biological aspects of the study); and Chief Z S Mtirara and all the members of the community advisory board. Mary Koss advised on questionnaire design and aspects of the study implementation.

  • Contributors: RJ was the project leader throughout the trial; wrote the proposal, led on the study design, intervention adaptation, and questionnaires; managed the study; directly managed the project from September 2004-April 2006; and did much of the data management and led drafting of the paper. MN contributed to the design of the intervention and questionnaires, developed operating plans for the implementation of the trial, was the project manager from September 2002-August 2004, and contributed to interpretation of the data. JL was project statistician, responsible for statistical aspects of study design, data management, and data analysis. NJ contributed to the design of the intervention and questionnaires, implementation of the trial, and interpretation of the data. KD contributed to the design of the study, data management, interpretation of the findings, and drafting of the paper. AP designed the protocols related to HIV and HSV-2 testing and quality control of the biological side of the study, and supervised the laboratory tests and storage of specimens and interpretation of results. ND contributed to the management of the study and the interpretation of the data. All investigators contributed to writing this paper. JL is guarantor.

  • Funding: National Institute of Mental Health grant No MH 64882-01 and South African Medical Research Council. KD was funded from the Harry F Guggenheim Foundation and by the Emory Center for AIDS Research (P30 AI050409).

  • Competing interests: None declared.

  • Ethical approval: University of Pretoria and University of Witwatersrand Ethics Committees.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

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