Exner TM, Mantell JE, Adeokun LA, et al. Mobilizing men as partners: the results of an intervention to increase dual protection among Nigerian men. Health Educ Res 2009 Apr 9. Epub.
Nigeria has the second greatest number of HIV-infected people in the world after South Africa. As of 2007, HIV prevalence was estimated at 3.1% among adults aged 15-29 years.(1) The HIV epidemic in Nigeria is predominately heterosexual. Evidence of risk among Nigerian men includes high rates of sexually transmitted infections,(2) inadequate knowledge about HIV,(2) and infrequent use of condoms.(3) Interventions focused on risk reduction among men in Nigeria have been successful, (4,5) An additional intervention in Nigeria appeared promising based upon its consistently high participation rate (>80%) but was not evaluated for efficacy. Based upon its high level of acceptance, this intervention served as a model for the development of an additional intervention based upon the Stages of Change Model.
To describe the development, implementation, and pilot evaluation of a sexual risk-reduction intervention among Nigerian men
Ibadan, the capital of Oyo state, southwestern Nigeria
A non-randomized intervention pilot study
Male adults (aged 18 years or older)
a) Risk perception, testing experiences, knowledge, and stigma; b) relationship context, skills, and intentions; and c) HIV risk behaviors
Men were recruited by self-referral from flyers posted in community venues (e.g. trade associations, markets, churches) and by asking women who were attending family planning clinics to refer their partner. Assignment to the intervention was based upon the geographic area from which the participants were recruited and were designed such that the demographic characteristics of the men in the intervention and control groups were similar. Consent was a two-step process, the first was to participate in screening and the second was for participation in the intervention or control group.
The intervention was developed using a participatory process that included US and Nigerian researchers, health and educational professionals, and young men from an advisory board associated with the previous program upon which this intervention was based. Evidenced-based interventions were reviewed and selected, then tailored to the population of interest.
The final intervention was a seven-module course delivered over two five-hour workshops scheduled one week apart with an additional two-hour 'check-in' session at one and two months post-intervention. Topics covered in the modules included HIV-related stigma; susceptibility to HIV and sexually transmitted infections (STIs), pregnancy and STI/HIV risks, risk-reduction strategies, sexual negotiation; challenging gender-based attitudes, and setting and implementing personal sexual risk-reduction goals. Sessions emphasized the communication, assertiveness, and negotiation skills requisite for practicing safer sex and attempting to foster positive safer sex and gender-equitable attitudes. A combination of methodologies, including didactic and interactive teaching, small group discussion, scripting behavior through vignettes and role plays, proverbs, songs, stories, and games was used.
Men assigned to the control group participated in a half-day didactic group workshop that included information on male and female sexuality; reproduction; contraception; and HIV/STI transmission, symptoms, treatment, and prevention.
The group interventions were led by two trained male facilitators. There were a total of four experimental and four control groups. Each group consisted of 25-30 men. Participants were interviewed at baseline and at three months post-intervention.
There were 149 men assigned to the experimental condition and 132 to the control. The demographic characteristics of the men in the two groups was similar except that men in the intervention group were older than those in the control group (mean age 39.8 years vs. 35.7 years, P<0.01). A total of 70% of men in the intervention group and 61% of men in the control group completed baseline and follow-up interviews. The demographic and outcome variables at baseline did not differ between those who completed the study and those who did not. Among men in the intervention group, 91% completed all sessions and 75% attended both of the monthly check-ins.
Controlling for baseline information and age, men in the intervention were significantly more likely to correctly identify venues for HIV testing in Ibadan (odds ratio [OR] 6.74, 95% confidence interval [CI]: 1.40-32.44) and their partners were more likely to have been tested (OR 10.73, 95% CI: 1.68-68.35) compared with comparison group men. Men who attended the intervention held significantly less stigmatized beliefs about HIV-infected people than did those in the comparison group (beta -.35, 95% CI: -0.26-0.11). Compared to men in the control group, men in the experimental group had lower expectations that condoms would be associated with a negative response (beta -0.19, 95% CI: -0.63 to -2.29) and reported significantly higher safer sex self-efficacy (beta 0.17, 95% CI: 0.02-0.28). Unprotected intercourse at the three-month follow-up was reported less frequently by the men in the intervention group (28%) than in the control group (54%) (OR 0.34, 95% CI: 0.17-0.68) as was refusing to use a condom with a main partner (12% intervention group vs. 32% control group; OR 0.28, 95% CI: 0.13-0.64). The mean number of episodes of unprotected vaginal intercourse was lower in the intervention group (2.02) compared with the control group (4.88) (beta -0.20, 95% CI: -4.74 to -0.55).
The findings suggest that this intervention is acceptable and possibly effective.
As a feasibility and proof of concept study the quality was very good. As an intervention and efficacy trial, it was inadequate because it was not randomized, allocation was not concealed, and there was no blinding of the assessor. In addition, although loss to follow-up was accounted for, it was high. The paper also did not include information on the eligibility criteria or the extent to which the participants were representative of Nigerian men.
Although the study was not able to establish efficacy because of the design, the findings are consistent with an effective intervention. It is worth noting that the intervention resulted in a decrease in unprotected intercourse, including episodes with a main partner. This result is important because much of the transmission of HIV in the region occurs within main partnerships. The intervention group reported less HIV-related stigma, which, although not as direct in reducing HIV transmission, may affect one's ability to engage in sexual risk-reduction and HIV testing. There appear to be important benefits of this intervention, but a rigorous randomized intervention trial is necessary to establish efficacy.
- UNAIDS. Report on the Global AIDS Epidemic 2008. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS, 2008.
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