Historically, men in sub-Saharan Africa are less likely to test for HIV, initiate antiretroviral therapy (ART), and remain engaged in care than women.1–5 Men may experience specific barriers to HIV testing and care, including hegemonic masculine norms, family or community expectations, conceptions related to care seeking, and the nature of the HIV testing and care environment.6–10 Further barriers may include lack of familiarity with clinics and having work hours that limit access to care.11 Failure to test for HIV and engage in care leads to increased morbidity and mortality for individuals living with HIV and undermines ART's promise for preserving health and preventing HIV transmission.12–15 In Côte d'Ivoire, where the national HIV prevalence among adult men aged 15–64 years is 1.7%, increasing HIV diagnosis and treatment among men is a priority.16 Although HIV prevalence in Côte d'Ivoire is low compared with many countries in southern Africa, progress toward the 90-90-90 goals has been slow. In 2017–2018, only 24.2% of HIV-positive Ivorian men knew their HIV status, only 70.7% of those who knew their HIV status self-reported current use of ART, and only 65.2% of those who self-reported current use of ART were virally supressed.16
To address male engagement with HIV testing and treatment, in 2013, the Johns Hopkins Center for Communication Programs (CCP) introduced the Brothers for Life Program (BFL) to Côte d'Ivoire in the form of mass media (television spots and a television series called “Réseaux”) and interpersonal communication (guided group dialogues). BFL was developed in South Africa in 2009 to mobilize men to take responsibility for their own health, promote positive male norms, and address risk and prevention behaviors associated with HIV.17 A core component of the program, and the inspiration for the name “Brothers for Life,” was to create a sense of fraternity and social support among participants.
To understand barriers to HIV testing and treatment among men in Côte d'Ivoire, a qualitative study was conducted between November and December 2016 across 3 urban and periurban sites: Abidjan (Yopougon), Bouaké, and San Pédro.18–20 Participants identified fear that an HIV-positive diagnosis would have negative consequences for their sexuality, work and financial success, family, social status, and health as the primary barrier to HIV testing and treatment.18,19 Participants suggested, however, that ART had the potential to mitigate the threat of HIV to the men's values.20
Using insights from the qualitative research, CCP adapted the ongoing Côte d'Ivoire BFL program to better address men's fears about HIV testing and treatment. This adaptation included additional modules on men's goals, HIV testing, and HIV treatment, as well as adding male peer navigators (PNs) to support HIV-positive BFL participants in initiating and remaining on ART. The approach was informed by a theory of change that hypothesized that content tailored to the aspirations of men—accompanied by social support from facilitators, male PNs, and other men in the group—would encourage men to adopt positive attitudes and behaviors regarding HIV testing and care.
The goal of this study was to describe the BFL program as implemented in Côte d'Ivoire, evaluate program implementation, and report uptake of HIV testing and treatment among BFL participants.
Setting, Participants, and the BFL Program
BFL was implemented in the following 3 sites where formative research was conducted: Abidjan (Yopougon), Bouaké, and San Pédro. The primary audience for BFL was men aged 25 years and older, married or unmarried, in both urban and periurban areas. Men were invited to participate in BFL through community leaders, professional networks, private sector companies, male social groups called grins, and peer-to-peer recruitment (men who participated were asked to invite other men).
Key components of the program included the following: (1) guided group dialogues, (2) video testimonials, (3) HIV testing, and (4) facilitated linkage to care by male PNs for participants testing HIV-positive. BFL groups consisted of 20–25 men from a given neighborhood. Together, the men determined the location, timing, and spacing of the sessions to best fit their schedules (five 2-hour sessions for a total of 10 hours). Group dialogues based on a structured male-centered curriculum delivered using a participatory facilitation approach formed the core of the BFL program. BFL facilitators were men, aged 30 years and older, who had experience working with people living with HIV. The BFL facilitators were recruited by local NGO implementing partners and trained by CCP staff to deliver the BFL curriculum, which included a session each on (1) men and sexuality, (2) men as lovers, (3) HIV preventing and testing, (4) adherence to ART, and (5) life skills. As part of these dialogues, men also watched and discussed two 10-minute video testimonials by Ivorian men living with HIV in which the men shared how they learned they had HIV, described their treatment journey, and spoke of their experience living happy, healthy, and fulfilled lives. Each BFL session lasted approximately 2 hours.
On-site (at BFL group venues) HIV testing services (HTS) were offered through local partners after the group had completed the session on testing. At first, HTS partners counseled the men on testing as a group, and then invited interested men to receive one-on-one testing. However, after the first 2 months of implementation, testing rates among BFL participants were lower than anticipated (63%), and the project switched to one-on-one counseling and testing.
We sought to assess implementation measures, including fidelity, acceptability, and reach of BFL program completion, testing, and peer navigation using qualitative and quantitative approaches.29
To assess BFL implementation fidelity, defined as the extent to which BFL facilitators adhered to the participatory facilitation style and the curriculum outlined in the BFL manual, trained local male data collectors directly observed all 5 sessions of 35 randomly selected BFL groups (for a total of 175 sessions). Assessment domains for facilitation fidelity included the following: (1) set up and introduction of session; (2) reflection; (3) skilled management of process; (4) skilled facilitation of discussion; (5) using listening and learning, building confidence, and giving support; (6) motivating continued participation; and (7) completion and submission of documentation (see Supplemental Digital Content 1, https://links.lww.com/QAI/B463 for the Fidelity Assessment Rubric). Domains of facilitation fidelity were assessed on a three-point scale as follows: 1—unsatisfactory, 2—somewhat satisfactory, and 3—completely satisfactory. The assessment domains for content fidelity included each of the 5 major topics and subtopics of the BFL curriculum. Domains of content fidelity were scored on a binary scale as follows: 0 (facilitator did not discuss subtopic) vs. 1 (facilitator did discuss subtopic).
Semistructured interviews with BFL participants were conducted to understand men's experiences and the acceptability of the format and content of the BFL program. Interviews were conducted by trained local male data collectors with 48 men who were purposively selected from among BFL participants who attended BFL groups in the eighth month of implementation (November 2017). The eighth month time point was selected to allow for an initial learning period and to correspond to maximum scale-up of the program. The desired sample included 15 of each of the following participant types: (1) men who chose not to test for HIV during BFL; (2) men who tested negative; (3) men who tested positive and did not initiate treatment; and (4) men who tested positive and initiated treatment. Only 4 men tested positive and did not initiate treatment; we conducted interviews with 3 of these men. Interviews with BFL participants focused on reflections about the program, decision-making around HIV testing, and experiences with treatment initiation for participants diagnosed with HIV. Goals of the interviews were to describe participant experiences with the program, including whether experiences were aligned with the underlying program goals, which aspects of the program were most valued, and whether men found the content and format acceptable. Specific program components of interest to the team were having a male space for discussion, a curriculum based on the intersections of men's goals and HIV, a person-centered approach, and convenient access to HIV testing. Interviews were conducted in French, audio-recorded, and transcribed in French for the analysis.
All men who joined BFL groups between April 2017 and January 2018 were invited to participate in the evaluation of HIV testing and linkage to care for those testing positive. Sociodemographic characteristics (age, marital status, children, religion, and education level) were obtained at enrollment from men who consented to participate. To describe completion of BFL sessions among participants, we randomly selected 400 men from 80 BFL groups before the first session and followed them to the fifth session. To describe reach of testing and peer navigation as well as test and care engagement outcomes, data were collected by CCP staff on HIV testing, HIV test results, acceptance of PN support if positive, enrollment in HIV care, CD4 count (at the time of treatment initiation), treatment initiation, and retention in HIV care 6 months after initiating ART. These data were abstracted from BFL program records and, among those testing HIV-positive, paper clinic charts at the clinical facility (CD4 count, ART initiation, and attendance at the 6-month follow-up visit).
Assessment of fidelity of BFL sessions was based on the observation instrument. Within each domain, points were summed and divided by the maximum number of possible points for that domain to generate an overall domain score and an overall score for facilitation fidelity and content fidelity. This score was then multiplied by 100 to arrive at a percent. These were compared with an a priori goal of a score of at least 80% on each. This a priori score was selected by the research team to reflect a realistic goal that also may reflect a minimum level of implementation required to achieve goals based on the experience of the research and implementation teams. Notably, this a priori goal was not validated.
The qualitative data were analyzed in Atlas.ti (GmbH, Berlin, Germany), in French, by 2 researchers fluent in French and English using a structured coding framework. The codebook was developed using both inductive and deductive approaches. An initial codebook was drafted based on formative research and existing literature on facilitators and barriers to HIV testing and treatment and included codes, such as most/least preferred sessions, description of participation in BFL, aspirations, knowledge, attitudes, gender norms, social support, stigma, HIV testing as part of BFL, and HIV treatment experiences.18–20 Examples of inductive codes included advocacy for BFL (where participants described their reasons for inviting others or asking the program to return to their neighborhoods) and behavioral intentions (where participants described changes they intended to make as a result of BFL that they had not yet implemented). Coders wrote memos to encourage researcher reflexivity and to incorporate emergent themes identified during the coding process. Viewpoints of participants toward BFL, HIV testing, and treatment initiation were compared and synthesized.
To describe participation in the BFL program, we calculated the percentage of men (from a random sample of 400) who had completed all 5 sessions. To describe reach of testing and peer navigation and the HIV testing outcomes, we used descriptive statistics for participant characteristics. We calculated care continuum outcomes with exact confidence intervals (CIs). We defined remaining engaged in HIV care as attending the 6-month HIV care visit as abstracted from the participant's medical record. Adjusted log-binomial regression was used to assess associations between participant characteristics and (1) HIV testing and (2) testing positive for HIV. The quantitative data were analyzed in Stata 15 (StataCorp, College Station, TX).
All participants completed written informed consent before participating in the semistructured interviews and the implementation evaluation. All components of the study were approved by the Johns Hopkins Institutional Review Board (IRB#7583) and the Comité National d'Éthique et de la Recherche (CNER) located within the Ministry of Health in Côte d'Ivoire.
Between April 2017 and January 2018, 7410 men participated in a total of 336 BFL groups. Of those, 97% (7187) agreed to participate in the evaluation. Table 1 summarizes the key implementation and program outcomes discussed in the Results Section. Among the 7187 men, the median age was 32 years [interquartile range (IQR): 28–41]. Most of the men were in a relationship (66.9%) and had children (63.1%) (Table 2 shows a summary of participant characteristics).
Across the 5 sessions of each of the 35 BFL groups randomly selected for the fidelity assessments, the mean overall facilitation fidelity score was 89%. The mean content fidelity score was 92%, reflecting the extent to which BFL facilitators covered each of the topics and subtopics in the program manual (Table 3). Both exceeded the a priori goal of 80%.
In semistructured interviews, participants expressed a positive value in meeting with other men in their communities and described gaining lifelong friendships (Table 4). Although men tended to emphasize the social support and increased willingness to be transparent about health concerns, some men felt shocked or hesitant to talk openly about sexuality and HIV with one another. Content related to sexuality and relationships resonated with men, particularly the emphasis on condom use, reducing multiple partnerships, and improving communication with their partners. Participants in semistructured interviews described an increased willingness to engage with people living with HIV, less fear of an HIV-positive diagnosis, and newfound understanding that an HIV-positive diagnosis is not a death sentence; one can live a fulfilled life with HIV by initiating and remaining on treatment.
Among the 400 men randomly selected before the first session, 84.4% reported participating in all 5 sessions. In terms of reach of testing, on-site HTS were offered at the venues of 247 (73.5%) of the 336 BFL groups conducted, during the intervention period. For the other 89 groups, HTS were scheduled for a later date, or participants were referred to a local HTS center. The primary reason HIV testing was not always offered during the BFL group was due to stock-outs of test kits. Additional reasons included scheduling conflicts and transportation challenges due to inclement weather that prevented HTS partners from reaching the venue. Testing for HIV during BFL reached 81% (n = 5835) of participants. There were no significant differences in reach of HIV testing based on the site where the BFL programs were delivered or whether or not testing was offered during BFL. Uptake of HIV testing was not significantly associated with site or participants' age, marital status, children, religion, or education (Table 5).
In semistructured interviews, some men described an increased willingness, or in their words “courage,” to be tested for HIV as a result of the program (Table 4). Men recalled key BFL messages, including (1) ART is free for all people living with HIV in Côte d'Ivoire; (2) early diagnosis and treatment initiation improves short-term and long-term health outcomes; and (3) with sustained treatment, one can continue to work, support one's family, and have uninfected children. There were men in semistructured interviews who reported an increased openness to test for HIV at some point but were “not yet ready” to do so as part of the program, despite general acceptability of the on-site testing.
Of the 5835 men who tested for HIV as part of BFL, 2.3% (n = 135) tested HIV-positive. Increasing age and having no education compared with a primary school education were associated with a positive result (Table 5). CD4 counts among men who tested positive ranged from 22 to 1475 cells/mm3, with a median of 669 cells/mm3 (IQR: 339–981) at the time of confirmatory testing and treatment initiation. Fifteen percent (n = 19) had a CD4 count of ≤200 cells/mm3. Of the 135 men who tested positive, 97% (n = 131) initiated treatment; 93% did so within 4 days of testing. Of the men who tested HIV-positive, 76% (n = 102) accepted PN support. The 4 participants who did not link to care declined PN support. After 6 months, 100% of the 131 men who initiated treatment remained engaged in HIV care (attended 6-month follow-up visit).
In interviews, HIV-positive BFL participants expressed that PNs facilitated linkage to clinical services and provided much appreciated moral support that helped them accept their HIV diagnosis (Table 4). Men described frequent encouragement from PNs to initiate and continue treatment.
Our findings suggest that the BFL program, as implemented in Côte d'Ivoire, was successful in encouraging participants to accept HIV testing, initiate ART promptly, and remain on ART. The fidelity assessments indicated that guided group dialogues were implemented as intended. The high fidelity scores reflect CCP's experience designing and delivering communication interventions and the rigorous training and supervision of BFL facilitators by CCP staff.
The acceptability assessment indicated an alignment between participant experiences and the theory of change, which posited that content tailored to the needs of men and strength-based counseling from PNs would encourage HIV testing and treatment initiation and retention (among participants diagnosed HIV-positive). Findings from semistructured interviews suggested that exposure to BFL content encouraged men to test for HIV and that the strong linkage and retention outcomes in this study were related to support from the PNs. Consistent with other literature, men in our study emphasized the role of PNs in offering (1) psychosocial support for accepting the HIV diagnosis, (2) emotional and logistical support to overcome a variety of barriers to initiating treatment, and (3) encouragement to remain on ART despite side effects.21–28
The assessment of reach of HIV testing (81%) and the uptake of peer navigation (76%) were encouraging. Notably, of the 81% of men tested for HIV as part of the BFL program, 97% of those testing HIV-positive linked to care, and 100% of those who linked to care remained in care 6 months later.
The study presents multiple ways of evaluating a community-based social and behavior change intervention in 3 distinct urban and periurban areas of Côte d'Ivoire. The study design was multifaceted and included an implementation evaluation with mixed methods fidelity, acceptability, and reach assessments. These multiple approaches allow us to triangulate data and deepen our understanding of whether and how participation in the BFL program may have encouraged men to test for HIV, initiate treatment, and remain on treatment. Findings from semistructured interviews suggest that the BFL program helped some participants overcome their fears and adopt more positive attitudes and behaviors around testing and treatment.
There are some important limitations to the study. First, given the recruitment strategy, we do not know how many men refused to participate in the group dialogues or how men who refused or were not effectively reached differed from the participants. Second, although the fidelity assessments were conducted by researchers independent of the implementing NGOs, we did not assess inter-rater reliability or validate the assessment tool in other ways. Third, this was a single-arm study without a control group; we cannot know for certain whether the BFL program was responsible for the observed outcomes because there is no meaningful counterfactual. Fourth, we did not collect information on whether participants had previously tested for HIV or whether they were living with HIV. As a result, it is possible that a proportion of BFL participants already had an HIV-positive or recent negative diagnosis. Finally, we did not collect data on the cost of the program implementation; this would have been useful to consider wider implementation.
The implementation of BFL in Côte d'Ivoire successfully achieved the goals of engaging men in discussions around HIV prevention, encouraging HIV testing, and achieving linkage to care, treatment initiation, and retention. Continued or expanded implementation of male-focused programs, such as BFL, may be an effective approach to identify HIV-positive men and support them to initiate and remain on treatment. Context-specific adaptations may have contributed to the success of the BFL program in Côte d'Ivoire and need to be considered when and where BFL is implemented in other settings.
Social and behavior change programs, such as BFL, have an essential role to play in supporting men to test, initiate treatment, and remain in care. BFL helped some men overcome their fears of HIV testing by transforming their perceptions of HIV treatment and living with HIV. With the support of PNs, men who tested positive through BFL initiated treatment promptly and remained in HIV care for at least 6 months.
1. Colvin CJ. Strategies for engaging men in HIV services. Lancet HIV. 2019;6:PE191–PE200.
2. Braitstein P, Boulle A, Nash D, et al. Gender and the use of antiretroviral treatment in resource-constrained settings: findings from a multicenter collaboration. J Womens Health. 2008;17:47–55.
3. Druyts E, Dybul M, Kanters S, et al. Male sex and the risk of mortality among individuals enrolled in antiretroviral therapy programs in Africa: a systematic review and meta-analysis. AIDS. 2013;27:417–425.
4. Ochieng-Ooko V, Ochieng D, Sidle JE, et al. Influence of gender on loss to follow-up in a large HIV treatment programme in western Kenya. Bull World Health Organ. 2010;88:681–688.
5. Tsai AC, Siedner MJ. The missing men: HIV treatment scale-up and life expectancy in sub-Saharan Africa. PLoS Med. 2015;12:e1001906.
6. Morrell R, Jewkes R, Lindegger G, et al. Hegemonic masculinity: reviewing the gendered analysis of men's power in South Africa. South Afr Rev Sociol. 2013;44:3–21.
7. Dovel K, Yeatman S, Watkins S, et al. Men's heightened risk of AIDS-related death: the legacy of gendered HIV testing and treatment strategies. AIDS. 2015;29:1123.
8. Fleming PJ, Dworkin SL. The importance of masculinity and gender norms for understanding institutional responses to HIV testing and treatment strategies. AIDS. 2016;30:157.
9. Fleming PJ, Colvin C, Peacock D, et al. What role can gender-transformative programming for men play in increasing men's HIV testing and engagement in HIV care and treatment in South Africa? Cult Health Sex. 2016;18:1251–1264.
10. Sileo KM, Fielding-Miller R, Dworkin SL, et al. What role do masculine norms play in men's HIV testing in sub-Saharan Africa?: a scoping review. AIDS Behav. 2018;22:2468–2479.
11. Camlin CS, Ssemmondo E, Chamie G, et al. Men missing from population-based HIV testing: insights from qualitative research. AIDS Care. 2016;28:67–73.
12. Barnighausen T, Herbst AJ, Tanser F, et al. 150 Unequal Benefits from ART: A Growing Male Disadvantage in Life Expectancy in Rural South Africa. 2014.
13. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. New Engl J Med. 2011;365:493–505.
14. Eaton JW, Johnson LF, Salomon JA, et al. HIV treatment as prevention: systematic comparison of mathematical models of the potential impact of antiretroviral therapy on HIV incidence in South Africa. PLoS Med. 2012;9:e1001245.
15. Underwood C, Hendrickson Z, Van Lith LM, et al. Role of community-level factors across the treatment cascade: a critical review. J Acquir Immune Defic Syndr. 2014;66(suppl 3):311.
16. Assessment CdIP-BHI. Summary Sheet: Preliminary Findings. 2018; Available at: https://phia.icap.columbia.edu/countries/cote-divoire/
. Accessed July 12, 2019.
17. Brothers for life website. 2020. Available at: www.brothersforlife.org
. Accessed February 14, 2020.
18. Naugle DA, Tibbels NJ, Hendrickson ZM, et al. Bringing fear into focus: the intersections of HIV and masculine gender norms in Côte d'Ivoire
. PLoS One. 2019;14:e0223414.
19. Tibbels NJ, Hendrickson ZM, Naugle DA, et al. Men's perceptions of HIV care engagement at the facility-and provider-levels: experiences in Cote d'Ivoire. PLoS One. 2019;14:e0211385.
20. Hendrickson ZM, Naugle DA, Tibbels N, et al. You take medications, you live normally: the role of antiretroviral therapy in mitigating men's perceived threats of HIV in Côte d'Ivoire
. AIDS Behav. 2019:1–10.
21. Craw JA, Gardner LI, Marks G, et al. Brief strengths-based case management promotes entry into HIV medical care: results of the antiretroviral treatment access study-II. J Acquir Immune Defic Syndr. 2008;47:597–606.
22. Gardner LI, Metsch LR, Anderson-Mahoney P, et al. Efficacy of a brief case management intervention to link recently diagnosed HIV-infected persons to care. AIDS. 2005;19:423–431.
23. Hoffmann CJ, Mabuto T, McCarthy K, et al. A framework to inform strategies to improve the HIV care continuum in low-and middle-income countries. AIDS Education Prev. 2016;28:351–364.
24. Chang LW, Kagaayi J, Nakigozi G, et al. Effect of peer health workers on AIDS care in Rakai, Uganda: a Cluster-Randomized Trial. PLoS One. 2019;5:e10923.
25. Richter L, Rotheram-Borus MJ, Van Heerden A, et al. Pregnant women living with HIV (WLH) supported at clinics by peer WLH: a cluster randomized controlled trial SpringerLink. AIDS Behav. 2019;18:706–715.
26. Hatcher AM, Turan JM, Leslie HH, et al. Predictors of linkage to care following community-based HIV counseling and testing in Rural Kenya. AIDS Behav. 2019;16:1295–1307.
27. Arem H, Nakyanjo N, Kagaayi J, et al. Peer Health Workers and AIDS Care in Rakai, Uganda: A Mixed Methods Operations Research Evaluation of a Cluster-Randomized Trial. AIDS Patient Care STDs. 2011;25:719–724.
28. Koester KA, Morewitz M, Pearson C, et al. Patient navigation facilitates medical and social services engagement among HIV-infected individuals leaving jail and returning to the community. AIDS Patient Care and STDs. 2014;28:82–90.
29. Proctor IE, Brownson RC. Implementation Research. Dissemination and Implementation Research in Health: Translating Science to Practice. 2012:1261.