The Substance Use, Gender, and Applied Research (SUGAR) program, directed by Dr. Wendee Wechsberg, applies a combination of gender-sensitive approaches, including behavioral, biobehavioral, and implementation research to reduce HIV, gender-based violence, heavy substance use, and other behaviors associated with adverse health consequences among under served and key populations globally, including women, adolescent girls and young women, couples, women who conduct sex work, LGBT+ individuals, people who use alcohol and other drugs, people who inject drugs, and racial and ethnic minorities.
The SUGAR program partners with community agencies and collaborative boards, comprised of citizens and professionals to better address culturally-relevant social and biobehavioral issues. SUGAR program projects aim to increase positive health outcomes through empowerment and gender equality driven approaches, including reducing the frequency of unprotected sex, sex while impaired, gender-based violence, heavy alcohol consumption, opioid and other substance use; as well as increasing the use of low-dead space syringes, antiretroviral treatment adherence and the development of goal-oriented personal health action plans.
SUGAR researchers implement a diverse range of methods to achieve project goals, including:
Global Reach and Impact
SUGAR researchers work locally and globally to produce results that have significant reach and impact, including ongoing research in North Carolina and South Africa.
Ongoing Projects
This study seeks to examine whether implementing a multilevel, woman-focused intervention, the Young Women’s Health CoOp (YWHC), for pre-exposure prophylaxis (PrEP) readiness is a viable complement to the South African Government’s HIV prevention plan. Specifically, this project aims to increase uptake of sexual and reproductive health (SRH) services and PrEP readiness among adolescent girls and young women aged 16 to 24 who engage in high-risk sexual behaviors and to reduce their barriers to accessing SRH services by addressing and reducing stigma and discrimination in clinics.
This two-stage collaboration among the University of North Carolina at Chapel Hill, the North Carolina Department of Health and Human Services, local health departments, and the North Carolina Harm Reduction Coalition works in the eight westernmost rural counties in North Carolina, which have been hard hit by the opioid epidemic. Stage 1 of this study is assessing service needs and service availability. In Stage 2, this project will work to increase service availability and link people in need to the appropriate services.
The PfS evaluation team—which includes members from RTI and the University of North Carolina at Chapel Hill—is assessing the short-, intermediate-, and long-term outcomes of the Prescription Drug Overdose PfS Program, which is funded by the U.S. Centers for Disease Control and Prevention (CDC). The program provides funding to awardees in 29 states. Awardees are required to enhance their prescription drug monitoring programs (PDMPs) and implement community or health system interventions. Short- and intermediate-term outcomes include increases in PDMP use and reductions in overprescribing of opioids. Long-term outcomes include reductions in opioid-related emergency room visits and in accidental opioid overdose deaths.
In collaboration with local health departments in North Carolina, this study aims to reach women of ages 18 to 25 from low-resource communities who have not been recently tested for HIV. The study is testing the relative efficacy of an adapted version of the HIV risk-reduction intervention, delivered via a tablet application compared with face-to-face delivery. This intervention for young, sexually active, African-American women who use substances is an adaptation of the original NC Women’s CoOp, an evidence-based HIV prevention intervention grounded in women’s empowerment, that has been adapted globally.
This study developed and tested an implementation strategy for adoption and sustainably integrating the Women’s Health CoOp (WHC) into existing clinics and substance use rehabilitation centers in South Africa. This project used a hybrid implementation science framework to assess barriers and facilitators associated with the implementation of the WHC. It also engaged key stakeholders, and addresses risk reduction among substance-using, vulnerable women living with HIV. Analyses are now underway.
This study builds on the YWHC project and is reaching female adolescents ages 16 to 19 who use alcohol and other drugs and have dropped out of school, living in socioeconomically disadvantaged communities in Cape Town, South Africa. This intervention aims to increase uptake of HIV counselling and treatment, reduce substance use, victimization, and sexual risk behaviors, and improve access to effective treatment and support services through linkages.
Select Completed Projects
This study sought to adapt and determine initial feasibility of a woman-focused, trauma-informed risk-reduction program that was modeled after the Women’s Health CoOp (WHC) and provided linkages to treatment for co-occurring substance use and victimization. This project was based in Cape Town, South Africa and reached women aged 18 to 25 who use alcohol and other drugs and had histories of trauma. Focus group participants and expert stakeholders viewed the trauma-informed WHC as highly relevant and acceptable. Outcomes showed promise, and qualitative interviews reinforced the need for continued interventions for women who have experienced trauma.
This implementation pilot project recruited 200 needle and syringe program clients in two cities in Tajikistan and completed follow-up interviews with 199 participants. The study demonstrated the feasibility of needle and syringe programs distributing low dead-space detachable needles and the acceptability of these needles to their clients. Future research will aim to scale up the program to all 50 needle and syringe programs in Tajikistan.
This study combined a biomedical strategy (seek, test, treat, and retain) with an evidence-based intervention (the Women’s Health CoOp) to reach at-risk, vulnerable women in Pretoria, South Africa, who use alcohol and other drugs. Preliminary outcomes suggested a decrease in the proportion of women using alcohol and other drugs and a decrease in gender-based violence between intake and follow-up appointments. In addition, women who needed antiretroviral therapy (ART) were referred and they showed greater adherence to their medication regimen. Additionally, a two-year teen supplement showed intervention feasibility and acceptability among a younger age range in Cape Town, South Africa.
HIV/sexually transmitted infection (STI) risk-reduction interventions are needed to address the complex risk behaviors among African-American female adolescents in economically disadvantaged communities in North Carolina. In a two-group randomized trial, this study reached 237 sexually active, African-American female adolescents who used substances, to test a risk-reduction intervention, the Young Women’s CoOp (YWC), relative to a nutrition control. In efficacy analyses adjusting for baseline condom use, at three-month follow-up participants in the YWC were significantly less likely to report sex without a condom at last sex relative to control. There were mixed findings for within-group differences over follow-up, underscoring the challenges for intervening with substance-using female youths.
The Women’s CoOp, best-evidence HIV prevention intervention, was adapted to address sexual safety among incarcerated women with histories of interpersonal violence (IPV). This resulted in the first trauma-focused HIV prevention intervention for women that directly addresses the sequelae of IPV within the context of HIV harm reduction. Participants' number of unprotected sexual occasions, posttraumatic stress disorder symptoms, and depressive symptoms decreased significantly from baseline to post-release. Effectiveness obtaining resources increased significantly from baseline to post-release.
This trial recruited men and their main female sex partners in Cape Town to participate in the Couples’ Health CoOp (CHC) intervention, aimed at reducing substance use, violence, and sexual risk behaviors among couples. Women in the CHC were less likely to be HIV positive at follow-up; men in the CHC were less likely to report heavy drinking and more likely to report condom use at follow-up than in other conditions.
This study tested the effectiveness of combining voluntary counseling and testing with the WHC among vulnerable women. This was the first trial in South Africa with women who use drugs to demonstrate that supplementing voluntary counseling and testing with a woman-focused intervention results in greater abstinence from drug use.
This study pilot tested the WC among pregnant African American women in substance abuse treatment in North Carolina. The study compared an adapted version of the intervention tailored to pregnant women with standard services offered in substance abuse treatment programs. At a 6-month follow-up, results indicated marked reductions in homelessness, use of cocaine and illegal drugs, and involvement in physical violence; there was also an increase in knowledge of HIV at this follow-up for both the control and intervention conditions.
This study determined the long-term effects of the WC intervention and booster sessions to help sustain risk reduction. Women who had been in the WC were found to be in a low-risk group at long-term follow-up.
To address the impact of HIV among African American women who use crack cocaine, a culturally specific HIV intervention—the Women’s CoOp (WC)—was developed in North Carolina. This intervention was effective in reducing sexual risk and increasing self-sufficiency. It is listed as a “best-evidence” intervention by the Centers for Disease Control and Prevention (CDC).
The SUGAR program partners with community agencies and collaborative boards, comprised of citizens and professionals to better address culturally-relevant social and biobehavioral issues. SUGAR program projects aim to increase positive health outcomes through empowerment and gender equality driven approaches, including reducing the frequency of unprotected sex, sex while impaired, gender-based violence, heavy alcohol consumption, opioid and other substance use; as well as increasing the use of low-dead space syringes, antiretroviral treatment adherence and the development of goal-oriented personal health action plans.
SUGAR researchers implement a diverse range of methods to achieve project goals, including:
- Respondent-driven sampling and peer outreach workers
- Randomized controlled trials to determine intervention efficacy, effectiveness, and comparative efficacy
- Gender- and culturally appropriate mixed-method data collection strategies
- HIV counseling and testing (HCT), drug and pregnancy testing, and referrals to community health services
- Implementation science to determine adoption and long-term sustainability in usual care settings
Global Reach and Impact
SUGAR researchers work locally and globally to produce results that have significant reach and impact, including ongoing research in North Carolina and South Africa.
Ongoing Projects
- PrEPARE Pretoria: Prevention, Empowering and Protecting Young Women in South Africa (2018-2023); NICHD
This study seeks to examine whether implementing a multilevel, woman-focused intervention, the Young Women’s Health CoOp (YWHC), for pre-exposure prophylaxis (PrEP) readiness is a viable complement to the South African Government’s HIV prevention plan. Specifically, this project aims to increase uptake of sexual and reproductive health (SRH) services and PrEP readiness among adolescent girls and young women aged 16 to 24 who engage in high-risk sexual behaviors and to reduce their barriers to accessing SRH services by addressing and reducing stigma and discrimination in clinics.
- Mitigating the Outcomes Associated with the Injection Drug Use Epidemic in Southern Appalachia (2017-2019); NIDA
This two-stage collaboration among the University of North Carolina at Chapel Hill, the North Carolina Department of Health and Human Services, local health departments, and the North Carolina Harm Reduction Coalition works in the eight westernmost rural counties in North Carolina, which have been hard hit by the opioid epidemic. Stage 1 of this study is assessing service needs and service availability. In Stage 2, this project will work to increase service availability and link people in need to the appropriate services.
- Cross-Site Evaluation of Prescription Drug Overdose Prevention for States (PfS) Program (2017-2019); CDC
The PfS evaluation team—which includes members from RTI and the University of North Carolina at Chapel Hill—is assessing the short-, intermediate-, and long-term outcomes of the Prescription Drug Overdose PfS Program, which is funded by the U.S. Centers for Disease Control and Prevention (CDC). The program provides funding to awardees in 29 states. Awardees are required to enhance their prescription drug monitoring programs (PDMPs) and implement community or health system interventions. Short- and intermediate-term outcomes include increases in PDMP use and reductions in overprescribing of opioids. Long-term outcomes include reductions in opioid-related emergency room visits and in accidental opioid overdose deaths.
- Young Women-Focused HIV Prevention: Seek & Test in North Carolina Clinics (2015–2020); NIDA
In collaboration with local health departments in North Carolina, this study aims to reach women of ages 18 to 25 from low-resource communities who have not been recently tested for HIV. The study is testing the relative efficacy of an adapted version of the HIV risk-reduction intervention, delivered via a tablet application compared with face-to-face delivery. This intervention for young, sexually active, African-American women who use substances is an adaptation of the original NC Women’s CoOp, an evidence-based HIV prevention intervention grounded in women’s empowerment, that has been adapted globally.
- Implementation Research for Vulnerable Women in South Africa (2014–2019); NIAAA
This study developed and tested an implementation strategy for adoption and sustainably integrating the Women’s Health CoOp (WHC) into existing clinics and substance use rehabilitation centers in South Africa. This project used a hybrid implementation science framework to assess barriers and facilitators associated with the implementation of the WHC. It also engaged key stakeholders, and addresses risk reduction among substance-using, vulnerable women living with HIV. Analyses are now underway.
- Expanding HIV Testing and Prevention to Reach Vulnerable Young Women (2015–2020); NIDA
This study builds on the YWHC project and is reaching female adolescents ages 16 to 19 who use alcohol and other drugs and have dropped out of school, living in socioeconomically disadvantaged communities in Cape Town, South Africa. This intervention aims to increase uptake of HIV counselling and treatment, reduce substance use, victimization, and sexual risk behaviors, and improve access to effective treatment and support services through linkages.
Select Completed Projects
- The PreTreatment CoOp (2015–2018); NICHD
This study sought to adapt and determine initial feasibility of a woman-focused, trauma-informed risk-reduction program that was modeled after the Women’s Health CoOp (WHC) and provided linkages to treatment for co-occurring substance use and victimization. This project was based in Cape Town, South Africa and reached women aged 18 to 25 who use alcohol and other drugs and had histories of trauma. Focus group participants and expert stakeholders viewed the trauma-informed WHC as highly relevant and acceptable. Outcomes showed promise, and qualitative interviews reinforced the need for continued interventions for women who have experienced trauma.
- Tajikistan Low Dead-Space Syringe Study (2013–2016); NIDA
This implementation pilot project recruited 200 needle and syringe program clients in two cities in Tajikistan and completed follow-up interviews with 199 participants. The study demonstrated the feasibility of needle and syringe programs distributing low dead-space detachable needles and the acceptability of these needles to their clients. Future research will aim to scale up the program to all 50 needle and syringe programs in Tajikistan.
- Combination Prevention for Vulnerable Women in South Africa (2011–2018); NIDA
This study combined a biomedical strategy (seek, test, treat, and retain) with an evidence-based intervention (the Women’s Health CoOp) to reach at-risk, vulnerable women in Pretoria, South Africa, who use alcohol and other drugs. Preliminary outcomes suggested a decrease in the proportion of women using alcohol and other drugs and a decrease in gender-based violence between intake and follow-up appointments. In addition, women who needed antiretroviral therapy (ART) were referred and they showed greater adherence to their medication regimen. Additionally, a two-year teen supplement showed intervention feasibility and acceptability among a younger age range in Cape Town, South Africa.
- The Young Women’s CoOp (2007-2013); CDC
HIV/sexually transmitted infection (STI) risk-reduction interventions are needed to address the complex risk behaviors among African-American female adolescents in economically disadvantaged communities in North Carolina. In a two-group randomized trial, this study reached 237 sexually active, African-American female adolescents who used substances, to test a risk-reduction intervention, the Young Women’s CoOp (YWC), relative to a nutrition control. In efficacy analyses adjusting for baseline condom use, at three-month follow-up participants in the YWC were significantly less likely to report sex without a condom at last sex relative to control. There were mixed findings for within-group differences over follow-up, underscoring the challenges for intervening with substance-using female youths.
- HIV/STI Risk Reduction for Incarcerated Women with Interpersonal Violence (2011-2015); NIMH
The Women’s CoOp, best-evidence HIV prevention intervention, was adapted to address sexual safety among incarcerated women with histories of interpersonal violence (IPV). This resulted in the first trauma-focused HIV prevention intervention for women that directly addresses the sequelae of IPV within the context of HIV harm reduction. Participants' number of unprotected sexual occasions, posttraumatic stress disorder symptoms, and depressive symptoms decreased significantly from baseline to post-release. Effectiveness obtaining resources increased significantly from baseline to post-release.
- The Couples Health CoOp (2008-2014); NIAAA
This trial recruited men and their main female sex partners in Cape Town to participate in the Couples’ Health CoOp (CHC) intervention, aimed at reducing substance use, violence, and sexual risk behaviors among couples. Women in the CHC were less likely to be HIV positive at follow-up; men in the CHC were less likely to report heavy drinking and more likely to report condom use at follow-up than in other conditions.
- The Western Cape Women’s 2007-2013; NICHD
This study tested the effectiveness of combining voluntary counseling and testing with the WHC among vulnerable women. This was the first trial in South Africa with women who use drugs to demonstrate that supplementing voluntary counseling and testing with a woman-focused intervention results in greater abstinence from drug use.
- Pregnant Women’s CoOp 2005-2010; NIDA
This study pilot tested the WC among pregnant African American women in substance abuse treatment in North Carolina. The study compared an adapted version of the intervention tailored to pregnant women with standard services offered in substance abuse treatment programs. At a 6-month follow-up, results indicated marked reductions in homelessness, use of cocaine and illegal drugs, and involvement in physical violence; there was also an increase in knowledge of HIV at this follow-up for both the control and intervention conditions.
- Women’s CoOp II Study (2004–2010); NIDA
This study determined the long-term effects of the WC intervention and booster sessions to help sustain risk reduction. Women who had been in the WC were found to be in a low-risk group at long-term follow-up.
- Women’s CoOp I Study (1998–2003); NIDA
To address the impact of HIV among African American women who use crack cocaine, a culturally specific HIV intervention—the Women’s CoOp (WC)—was developed in North Carolina. This intervention was effective in reducing sexual risk and increasing self-sufficiency. It is listed as a “best-evidence” intervention by the Centers for Disease Control and Prevention (CDC).