Evaluating Demand Generation (Stylish Man) for HIV/Family Planning Services Rakai

描述(由申请人提供)：为响应PAR-13-055《健康传播和实施研究》，我们建议测试一种新的需求产生战略--“时尚人”，以增加乌干达拉凯的艾滋病毒综合预防(CHP)的接受率。CHP包括循证生物医学干预措施，包括安全男性包皮环切术(SMC)、抗逆转录病毒疗法(ART)和预防母婴传播(p-MTCT)，以及行为干预。卫生防护方案可能会大大减轻艾滋病毒的流行；然而，最佳效果需要卫生防护方案覆盖率高。在PEPFAR的资助下，Rakai健康科学计划(RHSP)在乌干达Rakai区提供CHP。我们正在进行的54个村庄Rakai社区队列研究(RCCS)的社区艾滋病毒流行率从6%到42%不等，提供了关于CHP覆盖率的纵向数据，包括SMC、ART和p-MTCT；危险行为；以及HIV发病率。我们有初步证据表明，CHP正在降低Rakai的艾滋病毒发病率，但覆盖率仍然不理想(就像在非洲其他地方一样)，特别是在男性中，这降低了计划的影响。我们的数据表明，热电联产的供应并不是限制因素，而是存在“需求不足”。我们进行了广泛的定性研究，并确定了CHP吸收的障碍，这在男性中最为明显。基于这些数据以及社会认知理论和社会生态模型，我们开发并试行了一种以男性为中心的创新的CHP需求生成策略--时尚男性计划(SMP)，该策略对男性友好，不排斥女性。SMP努力通过淡化以健康为重点的信息，转而强调“主宰你的生活”，从而使卫生保健计划“非军事化”。SMP有两个不同但相关的元素：(1)通过电台和海报的大众媒体(MM)；以及(2)通过“时尚人活动”(SMEvent.)在社区层面进行动员，其中包括娱乐和比赛，内嵌生防护计划的宣传，以及立即获得服务。试点数据令人鼓舞(例如，来RHSP流动诊所接受包皮环切术的男性客户数量比之前的服务统计数据增加了四倍)。我们建议进行一项为期3年的随机分组试验，在25个RCC社区(总共50个社区)中，MM加SMEvents(干预组)和MM单独(对照组)的社区聚集成~12个组。主要结果将是ARM对CHP覆盖率(重点是抗逆转录病毒治疗、SMC、p-MTCT)的社区意向治疗率。我们还将监测关键行为和艾滋病毒发病率，并将它们与研究开始前在每个手臂的社区中观察到的几率进行比较。因此，次要结果将是艾滋病毒发病率、关键行为和CHP覆盖率在研究之前和研究期间的时间趋势。我们为所有的卫生保健服务提供了PEPFAR资金。该设计优化了效率，并将迅速提供非洲其他CHP项目创新需求产生的影响的数据。

DESCRIPTION (provided by applicant): 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.