Inroads for HIV Prevention among Men: Findings from Mixed Methods Research in the Context of the DREAMS Partnership in Southern Africa

"These meetings are like information hubs...I've learned that one must always have their [HIV] status checked because it is better to know." (South Africa, age 24)

Engaging men is a priority for the HIV response in sub-Saharan Africa - in part because heterosexual men contribute to disproportionately high HIV incidence among adolescent girls and young women (AGYW). To that end, the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) partnership purposefully built into its design community mobilisation with men/male partners of AGYW. This study investigates men's engagement in and response to HIV programming in the context of DREAMS in Eswatini and South Africa, among samples recruited largely at community hot spot venues to reach men at high risk of acquiring or transmitting HIV.

In terms of its work on male engagement, DREAMS works to: (i) reach men/male partners of AGYW with HIV services; (ii) reach men/male partners with programming that increases information and skills to reduce HIV risk behaviours, with a particular focus on changing harmful gender norms and mitigating intimate partner violence (IPV); and (iii) identify characteristics of men at highest risk of transmitting HIV to AGYW - and reach them with services and prevention programming.

The researchers conducted independent cross-sectional surveys in 2016-2017 (Round 1, or R1) and in 2018 (Round 2, or R2) with men in Eswatini (20-34 years-old, n = 1,391) and Durban, South Africa (20-40 years-old; n = 1,665), complemented by 74 in-depth interviews (IDIs) conducted from March-December 2018 with men exposed to HIV services/prevention programming. They assessed R1-2 trends in HIV risk factors and service use, overall and by HIV risk profiles.

HIV risk factors were prevalent in both countries at each survey round, but changes were found. Most men were engaged in HIV services (e.g., nearly two-thirds tested for HIV in the last year at R2, with large increases in Eswatini). In South Africa, from R1 to R2, there were declines in numbers of sexual partners in the last year from R1 to R2 (P < 0.001), including a decline from 24 to 13% in the proportion with 5+ partners, inequitable views towards gender norms (from 25% to 13% from R1 to R2; P < 0.001), hazardous drinking (52-43% from R1 to R2; P < 0.001), and transactional sexual relationships (44-53% with none, P < 0.01). In addition, consistent condom use increased from 21 to 25% (P < 0.05). (See the full paper for all data from both countries.)

In both countries, low levels of participation in HIV prevention meetings precluded assessing associations between such participation and HIV risk factors.

In each country, the researchers found four distinct HIV risk profiles, constituting a younger and older profile at markedly high risk. There were reductions over time among the highest risk profiles in South Africa. In Eswatini, in postestimation analyses, HIV testing in the last year, at 38-51% across profiles at R1, increased over time by about 15-25% in each profile (all statistically significant). Being circumcised (status) also increased in nearly all profiles, albeit not significantly.

The IDIs highlighted the following themes:

• Supportive messaging about the effectiveness of early HIV diagnosis and treatment was critical: This information/messaging was often communicated to men during pretest counseling and was consistently described as easing men's fears around testing and subsequently linking to care if HIV-positive. However, when asked, few men living with HIV in Eswatini and South Africa knew about the effectiveness of early HIV diagnosis and treatment for preventing transmitting HIV to their partners (i.e., treatment as prevention). However, less than 15% of survey respondents reported being reached by such programming.
• HIV prevention programming was eagerly received by men and supported positive behaviour change: Men consistently described welcoming the opportunity to participate in HIV prevention programming, which ranged from a few brief sessions to multiple more intensive sessions held over many weeks. Commonly reported effects of prevention programmes on men's HIV risk factors were reductions in numbers of sexual partners, improved communication and conflict resolution in relationships, and reduced violence in relationships. These changes were often described as arising out of the foundation of understanding the harm of control and power in relationships and importance of respect for others in one's community, particularly for more intensive, and/or mixed gender, programmes.
• Comprehensive prevention programming supported men to link to HIV services: Prevention programming that provided HIV information (reducing number of sexual partners; condom use) and referrals to HIV services, as well as critical reflection around dynamics and power/violence in intimate relationships and the importance of respect for others in the community, seemed to provide a foundation of information and support that facilitated engagement in HIV services, particularly among those formerly reluctant to do so.
• Men-only meetings played a particular role: Participants of men's meetings consistently described these meetings as providing opportunities for men to discuss the challenges they face and learn positive coping strategies, in addition to encouraging HIV risk reduction and linkage to services. Men who participated in men's meetings in each country rarely also participated in programming that included women.
• For some, men's meetings were an important entry-point for engaging in HIV services: By building trust because of recognition of men's need for mutual support around life challenges, men's meetings seemed to serve as an entry-point to learn about and link to HIV services. This was particularly the case for men at higher risk and/or those reluctant to join sessions they anticipated would be dominated by women.
• Convenient options facilitated routine HIV service use: For example, along with facility-based testing, there were mobile, door-to-door, workplace, and self-testing options. This expansion of convenient options was often described as a very recent change in Eswatini, where the survey also showed a large uptick in testing, while in South Africa it was described as the way things are now.

Per the researchers, these findings indicate that "Important inroads have been made to engage men in HIV services and prevention programming in the two countries, including among the high-risk profiles." Recommendations going forward include:

• Differentiated, client-centered services should continue to be provided as a complement to facility-based services and should continue to prioritise sharing information and supportive messaging around HIV treatment efficacy. However, the importance of reaching the highest-risk subgroups with HIV services remains.
• Supportive prevention programming that invites and meaningfully engages men (and male partners of AGYW), including in opportunities to discuss life challenges with other men, is promising for supporting uptake of services for previously reluctant men.
• Regarding the low participation of men in meetings related to HIV, DREAMS implementing partner organisations and donors have not reported large-scale refusal of men to participate when such programming was offered to them. Thus, further investigation is warranted to understand the optimal content and structure of prevention programming.

"In conclusion, findings from this study highlight critical inroads as well as lessons learned with regard to engaging men in the HIV response. They also underline the need for our field to continue to grapple with difficult questions around how we can build a more holistic and inclusive HIV response that meets the information, healthcare, and psychosocial support needs of the most vulnerable subgroups, and positively influences and capitalizes on existing shifts towards healthier and more gender equitable social contexts."