Evaluating Demand Generation (Stylish Man) for HIV/Family Planning Services Rakai
In response to PAR-13-055 for Dissemination and Implementation Research in Health, we propose to test a novel demand generation strategy, the "Stylish Man", to increase uptake of Combined HIV Prevention (CHP) in Rakai, Uganda. CHP includes evidence-based biomedical interventions, including safe male circumcision (SMC), antiretroviral therapy (ART) and prevention of mother to child transmission (p-MTCT), as well as behavioral interventions. CHP may substantially attenuate the HIV epidemic; however, optimal effects require high rates of CHP coverage. With PEPFAR funds, the Rakai Health Sciences Program (RHSP) provides CHP in Rakai District, Uganda. Our ongoing 54 village Rakai Community Cohort Study (RCCS), with community HIV prevalence ranging from 6% to 42%, provides longitudinal data on rates of CHP coverage, including SMC, ART and p-MTCT; risk behaviors; and HIV incidence. We have preliminary evidence that CHP is reducing HIV incidence in Rakai, but coverage remains suboptimal (as elsewhere in Africa), particularly in men, reducing program impact. Our data suggest that CHP supply is not the limiting factor, but that there is a "deficit in demand". We conducted extensive qualitative research and identified barriers to CHP uptake, which were most pronounced among men. Based on these data as well as social cognitive theory and the social ecological model, we developed and piloted an innovative male-focused CHP demand generation strategy, the "Stylish Man Program" (SMP) which is male-friendly without excluding exclude women. The SMP strives to "demedicalize" CHP by deemphasizing health-focused messages and instead stressing "taking charge of your life". The SMP has two distinct but related elements: (1) mass media (MM) via radio and posters; and (2) community-level mobilization via the "Stylish Man Event" (SMEvent) which includes entertainment and contests with embedded CHP promotion, and immediate access to services. Pilot data are encouraging (ex., a fourfold increase in the number of male circumcision clients coming to RHSP mobile clinics compared to prior service statistics). We propose to conduct a 3 year cluster randomized trial of MM plus SMEvents (intervention arm) compared to MM alone (control), in 25 RCCS communities aggregated into ~12 clusters per arm (50 communities in all). The primary outcome will be intent-to-treat community-level rates of CHP coverage (focus on ART, SMC, p-MTCT) by arm. We will also monitor rates of key behaviors and HIV incidence, and compare them between arms and to rates observed in communities in each arm prior to study initiation. Secondary outcomes will thus be time trends in HIV incidence, key behaviors and CHP coverage in each arm prior to and during the study. We have PEPFAR funding for all the CHP services. The design optimizes efficiency and will rapidly provide data on the effects of innovative demand generation for other CHP programs in Africa.