The Mpondombili Project: Preventing HIV/AIDS and Unintended Pregnancy among Rural South African School-Going Adolescents

Abstract

Unintended pregnancy, HIV and other sexually transmitted infections are major threats to the health of South African youth. Gendered social norms make it difficult for young women to negotiate safer sex, and sexual coercion and violence are prevalent. Sexual activity among adolescents is influenced strongly by conservative social norms, which favour abstinence. In reality, most young people are sexually active by the end of the teen years. Girls’ decision to have sex is often a passive one, influenced by partners. The Mpondombili Project is a school-based intervention in rural KwaZulu-Natal that aims to promote delay in the onset of sexual activity and condom use as complementary strategies for both sexually experienced and inexperienced youth. Interactive training was carried out with peer educators, teachers and nurses over a 15-month period, and a manual developed. The intervention was implemented in late 2003 with 670 adolescents in two schools. Issues covered included HIV/STI transmission, risk behaviours, HIV testing, pregnancy and contraception, gender inequality, sexual communication and negotiation, managing abusive situations, fear of AIDS, stigma and discrimination and sexual rights. The diversity of young people’s relationships and vulnerability to sexual risk call for the promotion of both risk avoidance (delay in sexual initiation) and risk reduction (condom use) together, regardless of ideology, especially where HIV is well-established, to protect their health.

Résumé

Les grossesses non désirées, le VIH et d’autres IST sont les principales menaces pour la santé des jeunes Sud-Africains. Les normes sociales différentes selon les sexes rendent difficile aux jeunes femmes de négocier des relations sexuelles protégées, et la coercition et la violence sexuelles sont fréquentes. Des normes sociales conservatrices recommandent l’abstinence aux adolescents. En réalité, la plupart des jeunes sont sexuellement actifs à la fin de l’adolescence. La décision des filles de passer à l’acte est souvent passive, influencée par leurs partenaires. Le projet Mpondombili, mené dans le KwaZulu-Natal rural, conseille comme stratégies complémentaires de retarder le premier rapport et d’utiliser des préservatifs aux jeunes sexuellement expérimentés ou non. En 2003, des jeunes, des enseignants et des infirmières ont dispensé une formation interactive sur 15 mois à 670 adolescents de deux écoles et ont préparé un manuel. La formation a abordé la transmission du VIH/des IST, les comportements à risque, le dépistage du VIH, la grossesse et la contraception, les inégalités sexuelles, la communication et la négociation sexuelles, la gestion des situations d’abus, la peur du SIDA, la stigmatisation, la discrimination et les droits génésiques. La diversité des relations entre jeunes et leur vulnérabilité exigent de promouvoir conjointement des stratégies destinées à éviter le risque (retard de l’initiation sexuelle) et le réduire (utilisation de préservatifs), sans souci d’idéologie, particulièrement là où le VIH a une forte prévalence.

Resumen

El embarazo imprevisto, el VIH y otras infecciones de transmisión sexual ponen en alto riesgo la salud de la juventud de Sudáfrica, donde las normas sociales basadas en género dificultan que las jóvenes negocien el sexo más seguro, y donde cunden la coerción y la violencia sexual. La actividad sexual de la adolescencia es muy influenciada por las normas sociales conservadoras, que favorecen la abstinencia. En realidad, la mayoría de la juventud es sexualmente activa antes de cumplir los 20 años. La decisión de las jóvenes de tener relaciones sexuales suele ser pasiva, influenciada por sus parejas. El proyecto de Mpondombili es una intervención escolar en la zona rural de KwaZulu-Natal, cuyo objetivo es postergar el inicio de la actividad sexual y promover el uso del condón como estrategias complementarias tanto para la juventud con experiencia sexual como para la inexperimentada. Se realizó capacitación interactiva con educadores de pares, profesores y enfermeras durante 15 meses, y se elaboró un manual. La intervención fue ejecutada en 2003 con 670 adolescentes en dos colegios. Los temas abarcados fueron: la transmisión del VIH/ITS, comportamientos de riesgo, pruebas de VIH, embarazo y anticoncepción, desigualdad de género, comunicación y negociación sexual, manejo de situaciones abusivas, temor del SIDA, estigma y discriminación y derechos sexuales. Debido a las diversas relaciones de la juventud y su vulnerabilidad al riesgo sexual, se debe promover tanto la prevención del riesgo (postergar el inicio de la actividad sexual) como su disminución (uso del condón), independientemente de ideologías, especialmente donde el VIH está bien establecido, a fin de proteger su salud.

Key Words:

• adolescents
• HIV/AIDS
• pregnancy
• dual protection
• abstinence
• condoms
• sexual initiation
• peer education
• South Africa

Adolescents in South Africa are at heightened risk of HIV infection. In a 2003 nationally representative household survey of youth aged 15–24 years, HIV prevalence was 10.2%. Among young women aged 15–19, 7.3 % were HIV-infected, compared to 2.5% of men the same age.¹ By the age of 20–24, 24.5% of South African women are HIV infected, compared to 7.6% of men. HIV prevalence in men peaks later, with about 20% of men in their 30s infected. Having an older partner is thus a key factor in increasing young women’s risk for HIV/AIDS. HIV prevalence was 29.5% among women aged 15–19 who had a partner who was five years or older than themselves compared to 17% if partners were within five years of their age.² The risk of pregnancy is also high, with one-third of women reporting pregnancy or a first birth before the age of 20.³ Most teenage pregnancy in South Africa is non-marital and unintended.⁴ Despite these risks, recent national survey data indicate some positive trends in young South Africans’ preventive behaviours. Awareness of HIV and how to prevent it is high, and reported condom use has increased rapidly over the past decade.¹² Thirty-three per cent of sexually active youth report always using a condom with their most recent sexual partner, while 57% of sexually active women report contraceptive use.¹ In our study of adolescents in rural KwaZulu-Natal, nearly half reported condom use at last sex.⁵ In spite of these trends, young people often are not dually protected against pregnancy and infection. Condoms remain most strongly associated with HIV prevention: among young women who use contraception, only 34% report use of the male condom for contraception, compared to 71% who use hormonal methods.¹

The gender dynamics creating barriers to prevention are powerful, including gender norms that make it difficult for young women to negotiate safer sex with male partners. They also encourage men to engage in risky behaviour, women to have relationships with older male partners and contribute to the prevalence of sexual coercion and violence.^{6 7 8} Such findings underscore the critical need for comprehensive sexual health interventions for adolescents that address both HIV/STIs and unintended pregnancy, as well as the social and contextual factors underlying young people’s risk. Without aggressive implementation of interventions in South Africa, there is a 50% probability that young people will be infected with HIV by age 35.⁹

A major issue, however, is what types of interventions are appropriate and most effective for young people. Unfortunately, HIV/AIDS prevention strategies for young people have become mired in an increasingly polarised global debate about abstinence versus condom use¹⁰ due to ideological, religious and cultural tensions related to sex and sexuality.¹¹ For instance, the primacy of abstinence has been promoted in abstinence and virginity clubs to delay sexual debut for adolescents in Uganda, Kenya, and South Africa,¹² and the US PEPFAR policy requires that at least one-third of funds for HIV prevention be earmarked for abstinence promotion among young people.¹³ Although Uganda’s ABC (abstain, be faithful, use a condom) approach has been widely credited in the decline of the country’s HIV epidemic, this claim has been contested.^{14 15 16} Evidence regarding the effectiveness of abstinence-until-marriage strategies in changing young people’s sexual risk behaviours is scarce. Most importantly, abstinence-until-marriage programmes do not address the reality that the majority of youth in sub-Saharan Africa are sexually active by the end of their teen years, and are at risk for HIV/AIDS and pregnancy as early as age 15.¹⁷ In South Africa, where the average age of marriage is late, at 27 years, but the median age at first sex is 17 years,³ strategies that promote abstinence-until-marriage are unrealistic. This stark fact argues for condom promotion as a key prevention strategy.

A major challenge for designers of youth prevention interventions is weighing the expected public health benefits of delayed sexual initiation, condom promotion or some combination of the two. In this paper, we describe formative research that preceded a school-based intervention, the Mpondombili Project, and its participatory development, designed to promote condom use and delay in the onset of sexual activity as complementary prevention strategies among rural South African youth.

Formative research: an initial step in intervention development

Despite a growing number of studies of adolescent sexual risk in South Africa, relatively few have been conducted in rural settings. KwaZulu-Natal, which is severely affected by HIV/AIDS, is South Africa’s most populous province and among the most economically disadvantaged.¹⁸ The study area consists of rural scattered homesteads, two small towns and a large trading centre situated on a national highway. Although many people live in remote areas, public transport links the rural areas to towns and cities. Annual average household income in the district is approximately US$650.¹⁹ About one-third of households are headed by women; there are five secondary schools, three clinics and one district hospital. Most residents are ethnically Zulu.

To gain an understanding of adolescent sexuality and risk behaviours, peer group discussions (repeat focus groups) with the same participants²⁰ were conducted with 53 adolescents aged 13–19, in four groups, divided by sex and age.²¹ The semi-structured discussions were conducted in isiZulu by two trained facilitators. Each group met eight times, exploring a range of topics related to gender, sexuality, pregnancy, HIV/AIDS and prevention. The group discussions were audio-taped, translated into English and transcribed.⁸, ²¹

The formative research identified critical intervention needs. Study findings showed that although adolescent girls were concerned about both pregnancy and HIV/AIDS, the threat of pregnancy was seen by the girls as more immediate, as they witnessed family and friends having children during adolescence. However, the consequences of HIV/AIDS were viewed as more serious. In contrast, adolescent boys did not perceive themselves to be vulnerable to HIV/AIDS, largely because many used condoms (although not with steady partners), and thought they could identify level of risk by a girl’s appearance or behaviour.

Gender, social norms and sexual activity

Similar to findings from other South African studies,⁶, ⁷, ^{22 24} the peer group discussions highlighted how gender inequalities contribute to and reinforce sexual risk behaviours. Adherence to traditional gender roles limited girls’ ability for sexual communication and negotiations with partners. Normative beliefs about gender roles pervaded discussions of sexual initiation and decision-making, forced sex and condom use. The discussions also pointed to many contradictions in young people’s belief systems, signifying that adolescent boys and girls’ normative beliefs and attitudes were not necessarily consonant with their behaviours. Within youth peer culture, young women are expected to be sexually available, to defer to male decision-making authority and to be “conquered”. Socio-cultural expectations, however, dictate that adolescent girls remain virgins, resist boys’ sexual advances and avoid pregnancy.²¹²⁴ Despite younger girls’ beliefs that it is ideal to delay initiation of sex until the age of 21 and favourable attitudes about abstinence, many were sexually active. Fear of parental disapproval of sexual relationships meant that sexual activity was often shrouded in secrecy.²⁵ In contrast, boys are expected to initiate sex, and often felt pressure from peers and older men, sometimes their own brothers or uncles, to uphold an image of masculinity through engaging in sexual activity. Those who chose to remain abstinent were often ridiculed. In practice, however, most of the young men interviewed rejected the idea of abstinence for themselves.²¹

Girls feared that their boyfriends would leave them if they refused to have sex, yet they were idealistic about their relationships, believing that if they could establish open communication with a partner at the onset of the relationship, they could influence sexual negotiations and their partners would respect their decision to refuse sex. Even with some fluidity in their beliefs, the belief that “girls don’t propose love to boys” was endorsed by many girls and boys.²¹ Among girls who had recently become sexually active, the decision to have sex was often a passive one, influenced by their partners’ persuasive powers and their own sexual naiveté.

Social norms regarding abstinence

National and local surveys in South Africa indicate that about half of young people in their teens are not sexually experienced.¹, ², ²⁶ Many girls expressed positive attitudes about abstinence in our formative research, citing protection from STIs and pregnancy as reasons. This perspective reflects community norms, whereby abstinence is a culturally meaningful option for many young women. Among younger girls, the majority view in the peer group discussions was that sexual activity was not appropriate until “older” ages. A minority of the sexually active girls in this age group supported the concept of “secondary abstinence”, i.e. periods of abstinence after having begun sexual activity, with avoidance of sexual intercourse as a way to prevent AIDS. Although these girls were concerned about rejection by their female peers if they did not have sex, they experienced even greater pressure to have sex from their boyfriends. Abstinence was not seen as a realistic prevention strategy among the older girls, however, who presumably were part of a peer group where sexual activity was more common.²⁵

Condom use and prevention

Most girls believed that boys should initiate male condom use, and therefore rarely discussed this topic before sex.⁸ Girls even felt it was easier to refuse sex than confront partners about using condoms, a surprising finding given young women’s disadvantages in negotiations within sexual relationships.⁶

There were many prevalent myths about condoms, including that they contain HIV and are therefore harmful rather than protective. Other South African studies have also noted negative attitudes about condom use, such as condoms should not be used with steady partners and a woman who carries condoms may be labeled a “bitch”.²⁷ Paradoxically, however, recent data show notable increases in condom use among South African youth, probably attesting to the power of public health education and HIV prevention messages in recent years.²

Developing the school-based intervention

These qualitative research findings were the primary source for shaping the focus and content of the Mpondombili Project. They highlighted two important influences on young people’s sexual risk behaviours: gender-role norms and inequalities, and social norms about sexuality. In order to achieve the project’s goals of dual protection through delayed sexual initiation and condom use, it was clear that the intervention would need to address these issues up front.

We drew on three other sources in designing the intervention: evidence from the literature about adolescent sexual and reproductive health knowledge, reviews of youth-focused interventions^{28 29 30} and existing HIV and pregnancy prevention interventions in South Africa.³¹³² Theoretically, the programme drew on theories of psychological and community empowerment,³³³⁴ gender and power³⁵ and social learning.³⁶

Although South African schools have been condemned for high levels of violence³⁷ and criticised for their limited capability to actively engage with HIV prevention,²⁷ we decided on a school-based intervention. A high proportion of young South Africans attend school, nearly 80% of 15–19 year-olds in this area.¹⁸ As a result, schools can be a major source of HIV/AIDS information and are an important institution for socialisation of youth, particularly in rural areas, and potentially for changing sexual behaviour norms.² However, sex education in schools has been inadequate. Despite a national mandate for Life Skills, teachers often have participated only reluctantly, and there is little oversight regarding how the programme is implemented in individual schools. School-based programmes pose further challenges since often they must include a fairly wide age range of youth with differing levels of sexual experience, who thus have different intervention needs. The Mpondombili Project’s dual focus on risk avoidance (delay) and risk reduction (condom use) arose from the need to address this diversity, as well as to respond to prevailing community norms about youth sexuality.

Engaging youth and adults in the process of participatory design

The Mpondombili curriculum was developed using a participatory process involving 14–17 year-old secondary school students and teachers, nurses and local and international researchers. The use of students as peer educators was intended to empower youth, foster knowledge-based leadership skills and self-confidence³⁸ and make the programme more accessible to youth. Many school-based programmes in Africa are delivered by teachers, do not engage youth actively in prevention, and have been guided by a top-down approach rather than young people’s self-identified needs.³⁹

As the Youth Peer Educators needed support to implement the intervention, the idea of “adult role models” emerged, whereby teachers from programme schools and nurses from nearby clinics would participate as mentors. The teachers felt that the nurses could more effectively address “technical” issues, such as HIV/AIDS, contraception and reproduction. However, nurses are often judgmental about adolescents having sex and therefore reluctant to provide contraceptives to them,⁴⁰ making it difficult for youth to feel comfortable talking about sex and contraception with them. The nurses’ participation in Mpondombili aimed to improve their understanding of young people’s needs and facilitate access to contraception and quality sexual health counselling at local clinics.

Interactive training for peer educators, teachers and nurses

To develop the intervention, project staff conducted interactive training with the peer educators and adult mentors over a 15-month period through workshops and consultations. Thirty-two youth peer educators were selected on the basis of their motivation, leadership capacity and interpersonal skills. A draft intervention manual was developed by the project staff, and used as the basis for training. Meeting weekly in small groups, the peer educators were asked to discuss and critique the main issues presented: gender – understanding the perspectives of the opposite sex, how gender shapes everyday lives, gender and sexuality, communication of information about safer sex, delay in sexual initiation, dual protection, sexual negotiation strategies and joint male–female responsibility for prevention. This process developed a critical consciousness through which the main issues of importance to the intervention emerged. Further, this process served as an educational tool to instil basic knowledge about HIV and pregnancy prevention, as well as other sexual health issues, in this group. At the same time, the youth peer educators were trained in participatory methods, and how to use games, role plays and interactive group discussion.

There were advantages and disadvantages to this process. While the training sessions raised young people’s confidence and knowledge, the reality of gender inequalities in the lives of South African youth became vividly apparent. At first, social interaction between male and female peer educators was limited, as they started off and remained in same-sex groupings. Whereas the boys participated actively in terms of comments and questions, the girls were more reserved. Some boys expressed negative viewpoints about changing gender roles, e.g. “Things have changed since women started to wear trousers”. The need to counteract male dominance led to doubling the number of female peer educators, expanding gender-sensitisation training of the peer educators and adult mentors, and addressing gender relations more extensively in the intervention.

The six teachers (three male, three female) and four nurses (all female) who participated in the project were keenly aware of the importance of providing HIV prevention and sexuality education to youth. However, the challenges were enormous. As members of the local community, these adults subscribed to the same beliefs about gender and sexuality. In particular, talking about sex in mixed adult–youth groups was difficult. Teachers and nurses are highly respected and wield power over youth, and asking both youth and adults to step out of their roles was initially difficult. Conceptually, the adult participants accepted ideas about gender equality, but implementation of these ideas was difficult. The nurses criticised colleagues who “shouted” at youth seeking condoms and contraception, but many believed that youth should not have sex and had inadequate knowledge of reproductive health and contraceptive issues. These issues were addressed through two one-day workshops on dual protection, gender and sexuality, and skills for talking to youth about sex and facilitation. The teachers, in particular, held many common misconceptions about HIV/AIDS. Ultimately, however, the teachers became the mainstay of support for the peer educators, with a formal role in the delivery of the intervention in classrooms. The nurses provided technical information about HIV/AIDS, pregnancy and contraception.

Implementing the intervention

The Mpondombili intervention was implemented in late 2003 with 670 adolescent girls and boys aged 14–17 in Grades 8–10 in two schools, in 40-minute sessions over a four-month period. These schools were not the same ones in which the formative research was conducted. Two additional schools served at comparison sites (n=313) for the formal quantitative evaluation. The intervention was approved by the Institutional Review Boards of the University of Natal (now KwaZulu-Natal) and New York State Psychiatric Institute, Columbia University. The curriculum included 15 sessions designed to create a positive approach to gender relations and build prevention skills. It focused on issues of gender, empowerment and sexuality as mechanisms to promote condom use and delay in initiation of sexual debut, and approached these goals by:

•	providing factual and realistic information on HIV/STI transmission and risk behaviours, HIV testing and rights, pregnancy and contraception, and substance use; and
•	addressing the social factors underlying sexual risk, including gender roles and inequalities, sexual partners, sexual communication and negotiation within relationships, sexual violence and coercion and managing abusive situations, fear of HIV/AIDS, stigma and discrimination, and sexual rights.

The intervention also addressed well-known barriers to condom use, such as beliefs in the ability to assess a partner’s HIV/AIDS risk based on appearance, the association of condom use with partner mistrust, promiscuity and infidelity,²¹⁴¹ sexual communication and condom skills negotiation. A combination of methodologies – didactic and interactive teaching, small group discussion, scripting peer behaviour through vignettes and role plays, proverbs, songs, stories, and games – was used to engage youth and facilitate skills development.

In response to issues raised during the participatory development process, fostering positive norms about gender and sexuality became a main theme of the intervention. The programme also aimed to increase adolescents’ comfort in talking about sex and to create a concept of healthy sexuality, whereby young people understood that being in a sexual relationship was okay, as long as they were “safe”. Gendered sexual expectations were challenged (e.g. a girl cannot ask a boy to use a condom, men who are virgins are not real men), and gender-equitable sexual relations were modelled. The tension between gender role expectations and cultural norms about sexual behaviour was repeatedly addressed, and students discussed the conflicts that girls in particular face in maintaining virginity and saving face with parents, while fulfilling the expectation to please boys.

The Mpondombili project stressed choices – delaying sexual initiation is the best way to prevent STIs and pregnancy, but if you have sex, condom use alone or in conjunction with another contraceptive is the only way to be protected. The intervention offered a wide range of safer sex options, including condom use and other intimate prevention strategies, such as kissing, cuddling, massage and touching yourself and your partner’s body and genitals. In addition, non-sexual means of obtaining pleasure, such as playing sports or cooking, were stressed.

The intervention also emphasised that choosing not to be in a relationship was okay, and that being in a relationship did not mean you had to have sex. Refusal skills, i.e. saying no to sexual intercourse, were modelled in role plays. For example, a vignette was used to stimulate discussion about the choice to wait before having sex, whether boys feel pressured to have sex before they are ready, what a couple should do if they cannot agree and how long they should wait before having sex. The youth participants offered the perspective that each couple should discuss sexual activity before a relationship becomes sexual, obtain their partner’s support and decide what is right for them.

The Mpondombili Project’s message about delay in sexual activity was linked to individual readiness, not to a specific time frame or marker like marriage. Strategies for delaying sexual activity, such as pledging not to have sex until matriculation or marriage, enlisting support from friends, avoiding friends who are unsupportive and engaging in alternatives to sexual intercourse were presented as options. However, to address the reality that most youth are unable to delay sex for more than a short period of time, the intervention focused on skills in negotiation, self-efficacy and empowerment. Throughout, the intervention emphasised the links between negotiating condom use and other aspects of sexual relationships, and gender beliefs and attitudes.

Stereotyped attitudes about condoms were also challenged, for example that only boys have negative attitudes toward condoms. Young people’s own contributions to the discussion were that talking about condoms when you are about to have sex is not the best time and that talking to a partner before sex makes it easier to protect yourself later. The intervention included demonstration of correct male condom use, followed by practice on a model, and male condoms were available at each session, an unusual benefit for a school-based intervention.

What did young people think about Mpondombili?

Young people’s reactions to the programme were very positive. The programme filled a huge need for quality sexuality and HIV prevention education. Perhaps most importantly, the presence of the intervention team provided a forum for young people to ask questions and obtain needed information and resources, including condoms, to enable self-protection. One of the main strengths of the programme was being able to directly address local ideas and stereotypes about gender, sexuality and HIV/AIDS. For the youth peer educators, involvement in the programme was clearly empowering. The female peer educators, especially, reported that they became a source of advice and guidance for many of their classmates. The impact also seemed to be positive for the young people who attended intervention sessions. A qualitative evaluation based on in-depth interviews with 41 students,⁴² suggested that the intervention had positive effects on beliefs and attitudes. Students primarily identified the intervention with HIV prevention and condom use, and less so with pregnancy prevention and delayed sexual initiation. Nearly all of them understood the main messages regarding dual protection. Many had positive attitudes about male condoms and indicated they wanted to practise dual protection; some attributed this to the intervention. Learning how to use condoms correctly was another perceived benefit. The freedom to talk about sex and relationships and to learn about self-protection were also seen as programme benefits since most adolescents were unable to discuss these issues with their parents. For some, there was greater understanding of the need to shift from traditional to more egalitarian gender roles, especially with respect to refusal of unsafe sex and partner violence.

Hannover, South Africa, 1999

Conclusion

The Mpondombili Project used youth peer educators along with teachers and nurses as adult mentors to deliver a gender and empowerment intervention with adolescent boys and girls in mixed-sex groups in schools. We incorporated young people’s issues regarding gender role norms with a standard HIV and pregnancy prevention approach that addressed consistent condom use, promotion of other contraceptive methods and open discussion between partners.

Our experience demonstrates the feasibility of developing a state-of-the-art intervention in an under-resourced setting, with substantial involvement of the target population of youth. The formal programme evaluation will be completed in early 2007, but observations from our process evaluation suggest a number of lessons learned – the intervention was labour-and time-intensive; schools are difficult environments in which to work; and changing norms and attitudes of youth, teachers and nurses entails great effort. Future interventions need to consider the gendered organisation and prevailing norms about sexuality that intersect the lives of these young people. Unequal gender norms persisted among the peer educators and the students and may have inhibited candid communication in a mixed-sex classroom setting. Holding same-sex groups could allow young people more opportunities to voice concerns about gender and sexuality and begin to break down gender barriers before a mixed-sex intervention is implemented. The Mpondombili Project’s lead teacher is working to establish Mpondombili as an NGO so as to expand the programme to other schools and to the community more broadly.

Regardless of programme structure, the complexity and diversity of young people’s relationships and vulnerability to sexual risk need to be considered in sexual and reproductive health programmes. This entails embracing risk avoidance (delay in sexual initiation) and risk reduction (condom use) as complementary alternatives, despite personal ideology or political agenda. Failure to address condom use and delay of sexual initiation simultaneously, especially in countries where HIV is well-established, will place young people at risk, denying them choices to protect their health.

Acknowledgements

This study was supported by NICHD R01 HD037343 OAR Supplement “Promoting Dual Protection among Rural South African Youth”, Theresa M Exner, Principal Investigator. The HIV Center for Clinical and Behavioral Studies is supported by a Center Grant from the National Institute of Mental Health (P30-MH-43520, Anke A Ehrhardt, Principal Investigator). Abigail Harrison is supported by NIH training grant NIDA 5T32DA13911. In South Africa, we acknowledge support from the Medical Research Council, Gita Ramjee, Director, HIV Prevention Research Unit, Durban, and especially the study team: Thobile Nzama, Pinky Kunene, Musa Mpanza, Muriel Kubeka and Mdu Gumede. Sincere thanks are due to the principals, teachers, nursing sisters and youth peer educators whose efforts made this project possible. Finally, we dedicate this article and the future of the Mpondombili Project to the memory of our colleague and friend, Nelly Ntuli (1962–2005), Project Director from 2000–2003.