Where are the Men: Finding the Missing Link

By: Daniel Were, PhD

Conflict of interest

• No conflicts to declare

Why Men?

• In Africa, HIV prevalence and incidence is higher in women than in men. However…

• Men account for 48% of people living with HIV globally

• Men are consistently less likely to know their HIV status than women

• Men under-utilize HIV prevention and treatment services

• Men contribute to onward transmission of HIV to others

• Men are more likely than women to die of AIDS-related illnesses

UNAIDS data, 2018

Men are Critical in Breaking the Cycle of Heterosexual Transmission

High HIV incidence men Mean age 27 years (range 23-35 years)

High HIV risk women Mean age 18 years (range 16-23 years)

Very young women acquire HIV from men, on average,

8 years older

Men and women > 24 years usually acquire HIV from similarly aged partners

When teen women reach mid-20s they continue the cycle

Dellar R, Tanser F, Abdool Karim Q, et al. Manuscript in preparation

High HIV prevalence womenMean age 26 years(range 24-29 years)

Multiple Combination Prevention Tools for Men

HIV Testing Coverage Lower Among Men

DHS Comparative Reports, 2013

Perc

enta

ge

ever

tes

ted

fo

r H

IV

Variations Between Men & Women in Progress towards 90-90-90

*Consolidated estimates from PHIA Data: Cameroon, Cote D'Ivoire, Ethiopia, Lesotho, Malawi, Namibia, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe

63%

73%

89%

92%

85%

87%

Tested Linked to Care Viral suppression

Intention is not translating to Action in VMMC – Why?

PSI Research & Metrics, “Zimbabwe (2013): Voluntary Medical Male Circumcision TRaC Study among men and women aged 15 – 49 years in Zimbabwe.” PSI Social Marketing Research Series, (2013)

100%

68% 66% 64%

11%

0%

20%

40%

60%

80%

100%

All Men Aware Interest Intention Circumcised

Intention → MCInterest → IntentionAwareness → Interest

Sample of 1,165 men, ages 15-49, conducted in October 2013

Why are men not getting services? What we know…

9

Lack of provider empathy

Fear of social stigma linked to HIV

Fear of pain and/or adverse events

Lost income when seeking services

Being HIV+ feels emasculating

Men deny and externalize risk

Lack of anonymity and confidentiality

Getting services is a time consuming hassle

HIV Testing has More Drawbacks and Fewer Gains for Men

Anticipated loss with no corresponding gain

Fear, not indifference Grief and trauma

Disclosure is frightening

Men are perceived as indifferent; but in reality they are scared, their HIV testing and linkage journey ischaracterized by fear and loss.

Provider empathy is not guaranteed

Testing positive means life collapses

Breaking the cycle of transmission, 2019

Reflections

• The global health field has come a long way in ensuring that services are available, but when it comes to motivating people to be better consumers of treatment and of preventive health services, there are relatively few proven interventions that promote uptake (Sgaier, 2016)

11

Sgaier et al., 2016. Interventions to drive uptake of voluntary medical male circumcision—A collection of impact evaluation evidence. JAIDS.

HIV acquisition is driven by behavior

and uptake of interventions is

driven by behavior

Dr. Nduku Kilonzo, Director, Kenya National AIDS Control Council

12

“

We Must Turn the Tide:

• How might we make HIV prevention services convenient and attractive to men?

• How might we make men CRAVE the services they NEED but FEAR?

• How might we make the benefits to outweigh the costs?

13

A Framework for Reaching Men

Jhpiego, 2018: Reaching Men for an AIDS Free Generation

15

1. Understand Clients

The CUBES Behavioral Framework

Engl E and Sgaier SK. CUBES: A practical toolkit to measure enablers and barriers to behavior for effective intervention design [version 1]. Gates Open Res 2019, 3:886.

Enablers & Barriers Influencers & Channels Enablers & Barriers

KNOWLEDGE INTENTION ACTION REPEAT HABIT

Deeply Understanding Client Perspectives…

17

Human Centered Design Behavioral EconomicsMarket Segmentation

Understand people’s Desires

Design a product or service that responds

Tell people: Make a compelling Promise

Make it easy to get Deliver on the Promise

Marketing:

Behavioral Economics

A data-driven approach to understanding the psychology behind human behaviors and attitudes

While human choices often seem non rational, this can be predicted…

Market Segmentation

• Age• Gender• Income• Marital status• Education

• Social status• Lifestyle• Personality • Values• Emotions

• Habits • Consumption • Loyalty• Frequency • Intent

Demographic Psychographic Behavioral

Market Segmentation for Oral PrEP: MSM Archetypes

SOCIALLY SUPPORTED BELIEVERS

Base: all uncircumcised men, n=1189

SELF-RELIANT BELIEVERS

FRIENDS DRIVEN HESITANTS

INDIFFERENT REJECTERS

SCARED REJECTERS

KNOWLEDGEABLE HESITANTS

TRADITIONAL BELIEVERS

17%

27% 6%

11%

19%

9%

10%

Moderate potential (11% of uncircumcised men), but high commitment and likelihood to advocate to wide audience; need to overcome some dissonance issue.

Moderate potential (9%), but easy conversion to action and highly likely to act as advocates for friends and to some extent other men.

Moderate potential (10%), but the key barrier is concern in safety which reduce motivation – increase of their commitment is relatively easy by addressing their issues.

Large potential (20%), but rather low motivation and need in additional assurance in need of VMMC. But can be easily converted by strong advocacy around them.

Large potential (17%) but low motivation and strong concerns , including fears and embarrassment – need a lot of support.

Large potential (27%), but hard to crack; absence of motivation and almost no concerns or fears, but could be reached via advocates in the community.

Small potential (6%), no need in support; have very high commitment driven by tradition.

Psychographic Segmentation for VMMC: Client Archetypes

Human Centered Design (HCD)

• Predominantly qualitative

• Offers a process, tools and techniques to:› Build programmers’ empathy,

connection, and respect for clients› More deeply understand the human

and emotional dimensions of a problem

› Catalyze an action-oriented creative problem-solving

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Mindset

Toolset Skillset

The Design Process

The Design Process Yields Insights = Windows of Opportunity!

How Might We…

25

MSM Key Insights for Oral PrEP Demand Creation

“I never see

pictures of people

like me in the

media. Nobody

understands what

it’s actually like"

MSM talking about stigmatizing and

patronizing content

“I don’t trust

many doctors, I

feel judged

about being an

MSM”

MSM talking about not trusting

advice from outside sources

“If a popular MSM

says no, then there's

no point even trying

to speak to any of

his boys.”

MSM talking about the role that peer

influence drives decisions

Clients Perspectives Providers Perspective on Clients

Insights from a PrEP Continuation Design Sprint: Conflicting Narratives

• Rational decisions

• Risk perception equals health seeking behavior

• Futuristic focus

• Risk and consequences

• Guidelines and prescriptive delivery of PrEP

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• Emotional decisions• Preoccupied with:

o Social perceptiono Stigma o Emotional needs (Love,

fear, respect, hope)o Does this feel good?o Living NOW

• Choices on how, when, where to receive PrEP

Reality Check???

27

MSM - BOLD STAKEHOLDERS - SUBTLE

2. Deliver Blended Program Activities to Achieve Impact

MSM Interventions for PrEP Uptake in Kenya: Jilinde Project

Let’s Get Real

1

Let’s Get Real Digital Media Campaign

5Collaboration with Family

Planning Leveraging current FP efforts

2Let’s Get Real Events

Initiated on PrEP

4,030*

*122% of target 12 months

before end of project

Insight Driven Demand Creation for VMMC in Zambia

Communication Strategy Pillars

Interventions

PROCEDURE WALK THROUGHBUDDY SYSTEMPAIN-O-METER

10-14

15-19 20-24 25-29 30-34 35 ANDABOVE

5%

28%

13%

3%1%

(n=8,247)

91%

of clients circumcised

between15-29 years

50%

Circumcised

0

10

20

30

40

50

60

70

80

90

100

Results

Increasing Uptake of VMMC: AIDS Free Malawi

• Optimization of Community Mobilizers

› Revamped selection criteria › Branded mobilizers› Enlisted satisfied clients › Revised training curriculum› Group incentives

AIDS Free Malawi Performance on 15-29 Age Group

147501 572

1,699

3172 3045

6340

2775 2686

4390

8981

1845

0

10

20

30

40

50

60

70

Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

Nu

mb

er o

f V

MM

Cs

VMMCs done in the Month Median Percent of Clients Aged 15-29 Years

Median Before

Median After

The ‘Khotla’ Men's Clinic in Lesotho

• Stand alone male clinic in a public hospital established in 2016

• Comprehensive integrated male friendly services under one roof

• Male service providers

• Clients doubled with over 10,000 clients served annually

• 14% positivity yield, compared to 3% for VMMC clients alone

Note: Yield for partners of FSW = 4.4% & Other Men at Risk = 2.3%

Footballer

1%Religious leaders

5%

Singers/ entertainers

2%

Unskilled laborers

25%

Businessmen

16%Skilled laborers

18%

State Representatives

9%

Drivers

18%

Others

1%

Peers

2%

Older men

3%

Targeting High Risk Men: Sauti Project in Tanzania

• Characterized male typologies (AGYW and FSW sex partners, MSM, General population)

• Mapping of male hotspots and workplaces

• Consultation with men’s sexual partners

• Engaging community leaders and men living/working in hotspots

• Provided male friendly services

180,602 (49.2%)

186,643(50.8%)

Targeting High Risk Men in Tanzania: Sauti Project

2.1%1.6%

6.3% 5.9%

4.4%3.8%

0.0%

4.5%

1.9%

7.7%

5.0%

1.9%2.8%

0.0%1.0%2.0%3.0%4.0%5.0%6.0%7.0%8.0%9.0%

New testersRepeated testers or unknown testing history

Men under 35: Yield by venue (Q1FY18)

Increasing Positive Yield through Index Testing: Kenya

3.3 2.7 2.4 2.4 2.2 2.4 1.5 1.0 1.39

2226

7

27

36

0

10

20

30

40

50

60

70

2011 2012 2013 2014 2015 2016 2017 2018 2019

Posi

tivi

ty r

ate

(%)

Duration (Years)

Routine male Routine male Index male Index female

*Routine testing includes provider and client initiated

Start of

Index Testing

Increasing Access: HIV Self Testing in Kenya

37

34,704sold to dateHIV test kits

17 pharmacies

testing kitsselling HIV self

60of clients are male

%

29 yearsmedian age

Conclusions

• Reaching women with HIV prevention and treatment interventions is not enough to stop the epidemic. We must reach men to reduce incidence among women and protect girls

• Men face numerous complex social challenges that discourage them from seeking HIV prevention services. We need to cultivate a deeper understanding of these challenges

• Innovative tools such as behavioral economics, human-centered design and market segmentation provide new ways of thinking and problem solving

• Jhpiego is applying these tools to catalyze millions of men to access HIV prevention services and address gaps in VMMC targeting, HIV testing, linkage to care, ART retention and PrEP continuation

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Acknowledgements

• Dr. Sema Sgaier – Surgo Foundation

• Jason Reed, Manya Dotson, Kelly Curran, Zebedee Mwandi, Gideon Mureithi – Jhpiego

• Anabel Gomez – AVAC

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South Africa

Zambia

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