Yaba guy che "for the guys": Intervention co-development to increase men's HIV service use

In Zambia, as in other sub-Saharan African countries, men are less likely than women to access HIV services, including HIV testing services, which acts as a gateway to prevention services and the HIV care continuum. As a consequence, men are less likely than women to know their HIV positive status, men initiate HIV treatment (ART) at later stages of infection, thus experiencing higher levels of morbidity and mortality once initiated on ART. Without knowledge of their HIV status, HIV positive men are more likely to transmit HIV to their sexual partners.

The barriers to men's engagement in HIV services are complex and multifaceted, and operate at national- through to individual-level. These include how healthcare services are funded, delivered and promoted, leading to healthcare facilities being seen as "female-spaces"; harmful gender norms related to masculinity, restricting men's use of HIV-related services and influencing their perceptions regarding their peers use of HIV-related services, and men's mobility for work, limiting their ability to access health facilities operational during conventional working hours. To improve men's engagement with HIV services, including HIV prevention and treatment services, a systems-wide approach to understanding and addressing these interacting barriers to service use is needed.

Through participatory qualitative research and crowdsourcing, this early phase study will work closely with men in an urban community in Lusaka, Zambia, to: 1) establish the barriers to HIV testing services and linkage to prevention and care that men perceive to be most inhibitive to their service use, and 2) co-develop a multi-component intervention to address barriers to service use. The multi-component intervention is intended to address barriers related to how and where HIV testing services are delivered, to transform norms related to HIV testing uptake and establish social support for use of HIV prevention services, in particular medical male circumcision, and initiation and uptake of ART.

In parallel, we will use time location sampling to assess whether this alternative sampling method, often used to reach "hidden populations", could be used to evaluate the impact of the multi-component intervention in a cluster randomised trial. The intervention will be finalised through a series of workshops with men residing in the study community and other stakeholders, including district health managers and healthcare workers, with support from these groups obtained before progression to a cluster randomised trial.

In Zambia, the PopART universal HIV testing-and-treatment intervention reached a large number of men, yet younger men aged 20-35 were less likely to be found at home during lay counsellor visits. Community-based hubs established post-PopART reached a high number of men and warrant exploration as a component of a broader strategy to provide HIV services to men. The aim of this study is to co-develop, with men aged 20-35, a multi-component intervention to address system-wide barriers to use of HIV services, including HIV testing and ART. The study will be conducted in an urban community in Lusaka. Participatory qualitative research and crowdsourcing will be used to meet the study objectives. Specifically, we will use community engagement, policy mapping, and participatory workshops to define barriers to HIV testing, and linkage to prevention and treatment services that men perceive as key to limiting their uptake of HIV services. We anticipate that norms will emerge as a key barrier to HIV testing and lack of social support as a barrier to linkage to prevention services and ART. We will adapt existing mobile phone support groups for use with men, to inform acceptability of virtual social support, and will launch an open call to crowdsource ideas on how to address barriers to HIV testing. Ideas will be shortlisted based on applicability, feasibility and likely cost, among other criteria. Subsequently, we will hold a series of workshops to finalise the intervention. The first workshop will refine the crowdsourced ideas, followed by two workshops with men resident in the study community to finalise the design of the broader intervention, including: social support components, location of community-based hubs and a logic model of the anticipated causal pathway of the intervention. Final workshops with regional and national policymakers, among other stakeholders, will refine the logic model and garner support for progression to the main study.