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

描述（由申请人提供）：为了响应PAR-13-055健康传播和实施研究，我们提议测试一种新的需求产生策略，即“时尚男人”，以增加乌干达Rakai的艾滋病毒联合预防（CHP）的吸收。卫生防护计划包括循证生物医学干预措施，包括安全男性包皮环切术（SMC）、抗逆转录病毒治疗（ART）和预防母婴传播（p-MTCT），以及行为干预措施。卫生防护中心可以大大减弱艾滋病毒的流行；然而，最佳效果需要高的热电联产覆盖率。利用总统防治艾滋病紧急救援计划的资金，拉凯健康科学项目（RHSP）在乌干达拉凯地区提供了卫生防护中心。我们正在进行的54个村庄Rakai社区队列研究（RCCS），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;艾滋病毒感染率。我们有初步证据表明，卫生防护中心正在降低Rakai的艾滋病毒发病率，但覆盖率仍然不够理想（与非洲其他地方一样），特别是在男性中，这降低了规划的影响。我们的数据表明，热电联产供应不是限制因素，而是存在“需求不足”。我们进行了广泛的定性研究，并确定了热电联产吸收的障碍，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，我们开发并试点了一种创新的以男性为中心的CHP需求生成策略，即“型男计划”（SMP），该计划对男性友好，但不排除女性。SMP通过减少对健康信息的强调，转而强调“掌控自己的生活”，努力使卫生防护计划“去医学化”。SMP有两个不同但相关的元素：(1)通过广播和海报的大众媒体；(2)透过“型男活动”（SMEvent）在社区层面进行动员，活动包括娱乐和比赛，并嵌入CHP推广，让市民即时获得服务。试点数据令人鼓舞（例如，与以前的服务统计数据相比，来到RHSP流动诊所的男性包皮环切患者数量增加了四倍）。我们建议在25个RCCS社区中进行一项为期3年的集群随机试验，将MM加SMEvents（干预组）与MM单独（对照组）进行比较，每个组约12个集群（总共50个社区）。主要结果将是有意治疗的社区一级卫生防护计划覆盖率（重点是抗逆转录病毒治疗、SMC和p-MTCT）。我们还将监测关键行为率和艾滋病毒发病率，并比较各组之间以及研究开始前各组社区中观察到的发病率。因此，次要结果将是研究前和研究期间每个组的HIV发病率、关键行为和CHP覆盖率的时间趋势。我们为卫生防护中心的所有服务提供了PEPFAR资金。该设计优化了效率，并将迅速为非洲其他热电联产项目提供创新需求产生效果的数据。

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.