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This quasi-experimental, proof-of-concept study evaluated the effects of an intervention designed to help Nigerian men decrease risk for HIV/sexually transmitted infections and unintended pregnancy. The intervention was delivered in groups during two 5-hour workshops, with a monthly 2-hour check-in session. A comparison condition consisted of a group-based half-day didactic workshop. Based on recruitment area, 149 men were assigned to the intervention and 132 to the comparison. Men were evaluated at baseline and 3-month post-intervention. At follow-up, men assigned to the intervention were almost four times more likely than comparison men to report condom use at last intercourse (P < 0.001) and to report fewer unprotected vaginal sex occasions, greater self-efficacy for negotiation, a more egalitarian power dynamic in their primary relationship, more positive expectations for condom use and greater intention for future consistent condom use (all P values < 0.05). Findings suggest that this intervention is both feasible and effective.
With a population of 131 million and the second largest number of HIV-infected people in the world, Nigeria is believed to have one of the most explosive epidemics in West Africa . HIV prevalence has increased rapidly, from 1.8% in 1990 to 3.1% among adults aged 15–49 in 2007 . The vast majority of HIV transmission in the region is through heterosexual activity, and women are disproportionately affected .
Managing Nigeria's HIV epidemic will require the development, implementation and evaluation of culturally sensitive interventions—including interventions for men. Evidence indicates that Nigerian men may be particularly vulnerable to HIV and other sexually transmitted infections (STIs) due to multiple sexual partnerships [3–6], inadequate HIV knowledge  and low condom use . Specific culturally normative behaviors of male control and power and lack of sexual communication  also need to be targeted.
Historically, reproductive health and HIV prevention initiatives often have bi-passed men as ‘uncaring and unconcerned victimizers’ [8–10]. Exclusion of men from contraceptive services further reinforces the erroneous notion that contraception is a woman's responsibility [9, 10]. In Nigeria, where ideal family size ranges from 5.8 among 15- to 19-year olds to 7.8 among 40- to 44-year olds, contraception use among married couples is low, with only 12.6% of married women reporting current use of any method in a recent national health survey . However, only 36.1% of the non-contraceptors cited desire for children as a reason for non-use, with 43.7% citing personal, partner or religious objections to birth control . Among all married women, only 1.7% report condom use .
In both developed and developing countries, men have not been effectively engaged in support of ‘dual protection’—use of a condoms alone or condoms in conjunction with an additional contraceptive—to simultaneously address both pregnancy and HIV/STI prevention needs.
Although a limited number of studies document HIV interventions that have targeted heterosexual men in industrialized nations [8, 12, 13], evidence of systematically evaluated HIV prevention and reproductive health interventions for men in developing countries is only recently emerging. A number of these have met with encouraging outcomes. For example, an intervention in India that used male opinion leaders to diffuse HIV/STI prevention messages was effective in easing gender-normative barriers to sexual communication, decreasing multiple partnerships and increasing condom use with female sex workers . A peer education intervention involving male clients of sex workers in Senegal increased AIDS awareness and knowledge and condom use and decreased sex with casual and paid partners . Similarly, encouraging results were found in an intervention targeting men who had extramarital sex with casual and paid partners in Kenya . In Nigeria, two recent studies showed significant effects on sexual behavior: a five-session individually administered intervention that focused on risk reduction messages resulted in decreased unprotected sex in casual partnerships among men in the military  and an intervention targeting youth in schools that included use of public lectures, peer outreach, health clubs in schools and provider training showed that intervention exposure increased access of STI treatment and decreased self-reported symptoms . In a review of interventions that included heterosexual men in both industrialized and developing countries, the authors concluded that, when men are directly targeted, interventions can produce reductions in risk behaviors .
Since men are regarded as both influential family and community leaders in Nigeria, their involvement in interventions has the potential to create effective and sustainable advocacy programs that change cultural gender norms and support reproductive health, HIV/STI prevention and population and development policies . In 2003, the Association for Reproductive and Family Health (ARFH) initiated a once-a-month, 10-session, group-based HIV/STI prevention program grounded in the Stages of Change Model  at five family planning sites in Ibadan, with ~25 attendees per group. This program used videos, discussion and modeling to (i) promote a personalized sense of risk, (ii) identify barriers to condom use (including culture and gender–role norms), (iii) provide skills to enact safer sex with a partner and (iv) motivate men to disseminate the dual protection message. There was no formal evaluation, but a high consistent participation rate (80%) and enthusiastic feedback demonstrated the capacity to recruit men and capture their commitment to a compelling psychoeducational group. This study capitalizes on that work, systematizing and extending those initial efforts. The purpose of this paper is to report on the development, implementation and pilot evaluation of an intervention promoting dual protection with heterosexually active men.
This study was conducted in Ibadan, the capital of Oyo State in Southwestern Nigeria. Oyo State has a high adult male literacy rate (80.5%) and low male unemployment rate (3.7%), with 59.4% of households classified as poor. In general, ~82.7% of urban residents in the state have access to satisfactory medical services.
The success of the informal ARFH educational program at reaching and retaining men led us to attempt to preserve the strength of the Nigerian program, while incorporating elements from evidence-based interventions that may have relevance for the Nigerian setting.
The curriculum was developed using a participatory process involving US and Nigerian researchers, ARFH nursing, education and research staff, men who had participated in the prior psychoeducational program and young men who were representatives from an advisory ARFH youth group. Senior investigators conducted two intensive 3-day interactive Intervention Development Workshops that introduced all attendees to manualized interventions and provided participants with hands-on experience in the development of group-delivered intervention activities. During the workshop, attendees were assigned to three- to five-person ‘Work Groups’ of ARFH staff and adult and teen men from the target communities, supervised by the senior investigators. Prior to convening the Intervention Development Workshop, the Nigerian and US investigators reviewed intervention manuals of evidence-based programs to identify pre-existing intervention modules that could be tailored to the local Nigerian context. These modules, coupled with elements of the Nigerian educational program, were used by the Work Groups as the basis for developing the intervention program. The goal was for the Nigerian teams to develop culturally relevant intervention activities and messages and to create an intervention the team could ‘own’. Each Work Group was charged with reviewing, adapting and augmenting pre-identified intervention materials pertinent to an assigned topic area (e.g. HIV knowledge, partner negotiation), with input from senior US and Nigerian investigators. By the end of the workshops, each Work Group had developed manualized exercises for its topic area, which were subsequently further refined by senior investigators. The intervention was further refined and finalized during the course of a Facilitator Training Workshop with the two men who would deliver the intervention.
The final intervention included seven modules designed to promote dual protection, delivered over the course of two 5-hour workshops, scheduled 1 week apart, with an additional 2-hour ‘check-in’ session 1- and 2-month post-intervention to review and support personal risk reduction goals. Modules covered confronting HIV-related stigma; promotion of knowledge of HIV/STIs and an accurate sense of personal susceptibility; understanding pregnancy and STI/HIV risks and prevention options; exploring risk reduction strategies (abstinence; male and female condom use, with and without use of an additional contraceptive); facilitating sexual negotiation (framed by the Work Group as capitalizing on Nigerian competence and pride in their innate skills as negotiators); challenging gender-based violence (including furthering norms within the group that challenge legally permissible wife beating) and setting and implementing personal sexual risk reduction goals. Sessions emphasized the communication, assertiveness and negotiation skills requisite for practicing safer sex and attempted to foster positive safer sex and gender-equitable attitudes. A combination of methodologies—didactic and interactive teaching, small group discussion, scripting behavior through vignettes and role plays, proverbs, songs, stories and games—was used to engage men and to facilitate skills development.
The comparison condition consisted of a half-day didactic, question-and-answer educational workshop on male and female and female sexuality, reproduction, contraception and HIV/STI transmission, symptoms, treatment and prevention delivered in a group.
The proof-of-concept trial was conducted between January and August 2005. A combination of strategies was used to recruit men. Female clients attending local family planning clinics were asked to deliver an invitation to their husbands/male partners, informing them of a reproductive health program for men and inviting their participation. Flyers were also distributed in diverse community venues (e.g. trade associations, markets, churches/mosques, government offices, transportation hub centers). In this quasi-experimental study, men were not randomized. Rather, condition was assigned based on the geographic area from which men were recruited; intervention and comparison areas were pre-matched to ensure comparable socioeconomic characteristics.
Following informed consent, all men who responded to the study advertisement underwent a 20- to 30-min eligibility screening for which they were paid the equivalent of US $2. Eligible men were then given a detailed description of the program, and those interested completed an additional consent procedure and were invited to attend either a single- or a multi-session workshop, based on recruitment area. Free transportation to the intervention sessions and lunch were provided.
All workshops were conducted at the ARFH site by two trained, carefully supervised male facilitators. Four two-session experimental and four one-session comparison interventions were delivered, with 25–30 men attending each session. The study was approved by the Institutional Review Boards of both ARFH and the New York State Psychiatric Institute/Columbia University, Department of Psychiatry. All study materials were translated into Yoruba by an experienced ARFH translator, with both assessment and intervention delivered in Yoruba.
Participants were interviewed at baseline and 3-month post-intervention by trained interviewers. Items, by domain, are described below.
Participants were asked to provide personal data regarding age, education, religious affiliation (Christian or Muslim), monthly income, socioeconomic status (lower/higher) based on recruitment sites and marital status (not married, monogamous or polygamous marriage).
Using a four-point Likert scale (grounded by 0 = not at risk and 3 = a great deal at risk), participants were asked to indicate ‘your view of your own risk’ for STIs and HIV in two separate questions. Fourteen items, developed by the Nigerian team and used in previous research, were used to assess participants’ ‘HIV knowledge’ based on a three-option response scale. The items covered the issues of HIV transmission, prevention and care. A ‘don't know’ response was regarded as lack of knowledge. Items were coded so that a higher score indicated higher HIV knowledge. HIV testing experiences were assessed by asking participants whether they knew where an HIV test could be obtained and whether they and their main partner had been tested for HIV. At follow-up, men were asked whether they were tested since their baseline interview and whether their main partner had ever been tested.
‘Social Exposure to HIV’ was assessed by asking participants whether they knew any HIV-positive person or anyone who had died of AIDS (1 = knew of someone, 0 = did not). ‘Stigma’ was assessed via seven items constructed by the Nigerian team. Using three response options (agree, disagree and not sure), men were asked how they felt about people living with HIV/AIDS, including items that assessed beliefs about how the virus was acquired, whether the virus was a punishment from God, personal comfort around infected persons and human rights of infected persons. A higher mean score indicates more stigma (α = 0.77 and 0.69 at baseline and follow-up, respectively).
The Nigerian and US team jointly developed two measures to assess the context of men's primary relationship with regard to the climate in which condoms were negotiated and power structure. ‘Relational Response to Condom Use’ was assessed via three items using a four-point scale (grounded by 1 = strongly agree and 4 = strongly disagree). Participants indicated the extent to which they believed their main partner would be angry or suspect sexual infidelity were they to request condom use and whether the participant would be ‘outraged’ if his main partner asked him to use a condom. A higher score indicates a more negative response to condoms (α = 0.84 and 0.64 at baseline and follow-up, respectively). Seven items were used to assess ‘Interpersonal Power’ in main partnerships. Participants rated whether they, their main partner or both equally ‘had the most to say’ regarding choice of friends, leisure and household activities, timing of serious discussions and of sex, contraception, condom use and general power in the relationship. A higher score indicates greater male dominance (α = 0.91 and 0.83 at baseline and follow-up, respectively).
Two skills-related variables developed by the Nigerian and US teams were assessed. ‘Comfort with Sexual Communication’ in primary partnerships was evaluated via three items (grounded by 1 = strongly disagree and 4 = strongly agree): ‘It is easy for me to tell my wife/main partner what I do or don't like to do sexually’, ‘My wife/main partner really cares about what I think about our sexual relationship’ and ‘Talking about sex with my wife/main partner is usually fun for both of us’. A higher score indicates better sexual communication (α = 0.64 and 0.63 at baseline and follow-up, respectively). To assess ‘Safer Sex Self-Efficacy’, participants rated on a four-point scale (grounded by very unsure = 1 and very sure = 4) how certain they were that they could perform 11 safer sex-related behaviors (e.g. discuss HIV/STI prevention with their partners, assess partner risk behavior, convince a long-term or new partner to use a male or female condom; α = 0.88 and 0.82 at baseline and follow-up, respectively).
We also evaluated ‘Intentions for Condom Use’, with participants indicating the likelihood of using a condom every single time they had vaginal or anal sex in the next 6 months on a six-point response scale (from 1 = ‘very unlikely’ to 6 = ‘very likely’).
Sexual behavior was assessed separately for main and ‘other’ partners. Participants reported the number of occasions of vaginal intercourse in the prior 3 months and the number of those occasions protected by condoms. Since dual protection was our central focus, condom use, with or without the use an additional contraceptive, was the central focus of evaluation. A single binary variable was created to reflect whether or not there were any occasions of condom-unprotected vaginal intercourse in the prior 3 months (yes = 1, no = 0). Condom use the last time the participant had vaginal intercourse with their main partner also was assessed and was specified a priori as the major study outcome. Men additionally were asked at baseline whether they had ever refused condom use with their main partner and, at follow-up, whether this had occurred since baseline.
Descriptive statistics and contingency tables are provided to indicate the proportion of men and mean values by condition for key variables. To assess differences by condition at baseline and follow-up and examine differences between participants with and without follow-up data, logistic regression and t-tests were used for categorical and continuous variables, respectively. Given the non-random design, all follow-up analyses controlled for baseline values. Although men did not differ significantly at baseline in education, marital status, religion, occupation or income, there was a significant difference in age by condition at baseline [mean = 35.7 for comparison and 39.8 for intervention; F = 8.41 (df = 1178), P < 0.01]. Therefore, confirmatory follow-up analyses examining differences by condition were conducted both with and without controlling for age.
Men enrolled in the trial ranged in age from 18 to 73 years (median age = 38; 23% were in their teens or 20s, 31% were in their 30s, 36% were in their 40s and 10% were ≥50). Eighty-eight percent were married, with 7% of marriages polygamous (the sample was 44% Moslem and 56% Christian). Fifty percent of men had not completed secondary education, 17% had completed high school and 33% had attended college. Men were drawn from diverse occupational groups that included auto repairs and services, transport and the civil service. The sample was evenly divided among men whose income was regular and irregular. Twenty-two percent earned a monthly income of <N5000 ($39.06) and 29% earned ≥N25000 ($195.31). Most men (90.1%) reported sexual activity in the prior 3 months at follow-up; only 23 men (12.4% of those with follow-up data) reported sex with a non-main partner at follow-up.
Of 149 men assigned to the experimental and 132 assigned to the comparison conditions, 105 interventions (70%) and 80 comparison men (61%) completed both baseline and follow-up interviews (total follow-up rate = 66%). Those who did not complete the follow-up assessment did not differ significantly from those who did on baseline demographic or outcome variables. Among men in the experimental condition, 91% attended both 5-hour sessions and 75% attended both monthly check-ins.
Table I presents follow-up data on risk perception, HIV testing, knowledge and stigma by condition. Three-month post-intervention, men in the intervention and comparison arms did not differ significantly in the proportion who felt at risk for HIV and STIs, nor on their risk ratings. Controlling for baseline and age, men in the intervention had approximately seven times the odds of correctly identifying venues for HIV testing in Ibadan, and their partners were 10 times more likely to have been tested compared with comparison group men; intervention men also had higher rates of HIV testing post-intervention, although this was a trend finding (P < 0.06). Men who attended the intervention held significantly less stigmatized beliefs about HIV-infected people than did those in the comparison group.
Relative to comparison men, those exposed to the intervention had significantly lower expectations that condoms would be associated with a negative response in the context of their primary relationship and reported significantly higher safer sex self-efficacy (Table II). The power dynamic in the primary relationship of men in the intervention was significantly less male dominated than among comparison men, and intervention men had more than twice the odds of intending to use condoms consistently in the coming 6 months.
As shown in Table III, the intervention significantly affected sexual risk behavior. Compared with comparison men, those in the intervention had one-third the odds of engaging in unprotected sex in the prior 3 months and were approximately four times more likely to report condom use at last vaginal intercourse with their main partner. They also had approximately a third lower odds of refusing condom use with a main partner and reported significantly fewer unprotected vaginal intercourse occasions. The proportion of intervention and comparison men with non-main partners in the prior 3 months did not differ significantly.
To examine possible dose effects, secondary analyses were conducted to assess the impact of number of intervention and check-in sessions attended on the outcomes for the intervention versus comparison group. Attendance had no effect on outcomes (data not shown).
The overall pattern of findings strongly suggests that the intervention has merit. The intervention, carefully tailored to the needs and culture of Nigerian men, resulted in reductions in unprotected sex, increased condom use at last intercourse and improved intentions to use condoms consistently, particularly in the context of main partnerships. This is especially pertinent in sub-Saharan Africa and other settings in the developing world, where evidence suggests that many women are contracting HIV within the context of their primary relationships . It is notable that men in the intervention, relative to comparison men, reported a power dynamic in their primary relationship characterized by lower male dominance at follow-up and held less negative expectations for a negative response to raising the issue of condom use within their main partnerships. Thus, although only men were targeted by the intervention, the intervention potentially benefited men's partners, not only in terms of sexual risk reduction but also by fostering a more gender-balanced climate in primary relationships and creating important attitudinal shifts and expectations that may support and sustain changes made.
There also was a reduction in HIV-related stigma. Beyond the social and ethical importance of un-demonizing HIV, reductions in HIV-related stigma can be an important precursor to being able to personalize risk of HIV, including viewing condoms as a relevant and reasonable issue .
The issue of feasibility of intervention implementation is particularly important. The fact that relatively few interventions targeting heterosexually active men have been evaluated in part may be attributable to beliefs that ‘men will not attend a group intervention’ or ‘men are not interested in prevention’. Over 90% of men assigned to the intervention who completed the 3-month follow-up assessment had attended both half-day sessions and 75% attended both check-in sessions, suggesting that at least some men will come and some men are interested in prevention—particularly when designed with input from the men the intervention is trying to reach. The quasi-experimental nature of the design, a relatively small sample size that could mask meaningful baseline group differences due to low power, lack of an attention control and a moderate loss to follow-up limit the ability to draw firm and generalizable conclusions. Nonetheless, findings suggest that this group-based, cognitive–behavioral intervention is both feasible and potentially effective and should be more rigorously evaluated in a future randomized controlled trial.
National Institute of Child Health and Human Development (R01-HD37343) to T.M.E.; National Institute of Mental Health (T32-MH19139; Behavioral Sciences Research in HIV Infection; Principal Investigator, Anke A. Ehrhardt; Training Director, Theo Sandfort) at the HIV Center for Clinical and Behavioral Studies (P30-MH43520; Principal Investigator, Anke A. Ehrhardt) to I.A.U.
The authors thank the men who participated in this study and the professional and committed ARFH staff who contributed to the development and execution of this study.