South African Men Health Promotion Project

Sub-Saharan Africa has just over 10% of the world's population, but according to UNAIDS was home to more than 60% of all people living with HIV in 2003-some 25.4 million people. South Africa continues to have the largest number of people living with HIV in the world. As in other parts of sub-Saharan Africa, heterosexual exposure is the primary HIV transmission category. An estimated 5.3 million South Africans-2.9 million women and 2.4 million men-were living with HIV at the end of 2003.

Worldwide, efforts to stem the spread of HIV among heterosexuals have stressed the impact of HIV on women. Oft-cited statistics indicate that about half of all people living with HIV are women. It is often suggested that women are seldom free to make empowered choices and face a range of HIV-related vulnerabilities that men do not face-many of which are embedded in the social relations and economic realities of their societies. Women's economic dependence on their male partners and the fact that women do not have the power to abstain from sex or to insist on condom use-even when they suspect that their man has other sexual partners and might have HIV-is emphasized. The hazards of young women's sexual relationships with older men and the high rate of rape and other forms of sexual coercion are cited. Men are typically mentioned as injection drug users, as having sex with other men-whether as MSMs or being on the "down low"-or as being the cause of the spread of HIV in women. The strategies typically offered to address the impact of HIV on women are interventions with women. For instance, it is recommended that women be taught the information and skills to make decisions about the terms of their sexual relationships, that methods of protection that women can control (e.g., microbicides) be developed, and that boosting women's economic opportunities and social power should be seen as part and parcel of potentially successful and sustainable HIV prevention strategies.

To be sure, there is an alternative approach to addressing women's risk of heterosexual transmission of HIV, one that would be important complement to the predominant approach: namely, focusing on men. Although it is noted that HIV is affecting women most severely in places where heterosexual exposure is a dominant mode of transmission, this seldom leads to a recommendation that interventions be developed to change men's behavior. Yet, by reducing men's sexual risk behavior, it should be possible to reduce rates of HIV in both men and women. Men's rates would decline because they are the recipients of the intervention; women's rates would decline because they have sex with men. Interventions targeting men could take into account the power that men have in sexual decision-making and risk taking.

However, whether one considers the US literature or the international literature, few randomized controlled trials (RCTs) of HIV/STD risk-reduction interventions have targeted heterosexual men. Elwy and colleagues 2002 review of HIV/STD prevention intervention studies revealed that only 12 of 1157 studies worldwide were conducted on males only. Most were not RCTs demonstrating intervention efficacy. Only 2 demonstrated significant effects on mediators and behaviors, and neither was a RCT. In addition, scant attention has focused on the general population of heterosexual men in any region. Indeed, 8 of the 12 studies focused on incarcerated men, STD patients, substance abusers, miners, or truck drivers. To address this gap in the literature, the proposed trial will focus on men who are more representative of the general population. In many developing countries, including South Africa, the HIV/AIDS epidemic is generalized, and there is a need to develop and test interventions for a broad range of the population, not just special high-risk sub-populations.

Accordingly, the purpose of this research is to develop and test the efficacy of an intervention to reduce behaviors that create the risk for contracting and transmitting STD, including HIV, among South African men who have sex with women. A cluster-randomized control trial design will be used to reduce the potential for contamination between treatment arms that would be present if individuals were randomized. An attention control group will be used to control for Hawthorne effects, special attention, and group interaction. Men will be recruited from Black townships surrounding East London, including Mdantsane, Scenery Park, Duncan, Village, and Gompo Town, and the semi-rural area of Berlin in the Eastern Cape Province of South Africa. More than 98% of the residents of these areas are Black Africans, and isiXhosa is the first language for 98.8% of the population. There are 206 neighborhoods defined as geographical clusters tied to census data in this catchment area, allowing the creation of 103 matched pairs of neighborhoods similar on the percentage isiXhosa-speaking, percentage married, percentage male, percentage living in informal dwellings, percentage unemployed, and population size. From the 103 matched pairs, 22 pairs will be randomly selected for the trial. One neighborhood in each pair will be randomly assigned to each of the 2 study arms.