1. REACHING MEN Using data to focus programs on specific locations and populations for maximal impact
George Siberry, MD
ICASA
December 2017

2. Finding men:
Reviewing program & survey data to identify disparities in coverage by sex

3. Males lag behind females in HIV Testing
Progress Toward First 95 by Sex
Country
Female (%)
Male (%)
Lesotho 82 71
Malawi 76 67
Swaziland 89 78
Zambia 77 70
Zimbabwe 63
Sources: UNAIDS Progress report, *PHIA fact sheet, ** SDS (Denominator = All PLHIV)

4. Treatment coverage among men lags behindF M

5. Namibia: National ART Gap by Age and Sex Young men and women aren’t on treatment
Source: PEPFAR Namibia & UNAIDS, 2017

6. Cote d’Ivoire: ART Targets through 2020
Years
Target ART (All)
Target ART Coverage (All)
Male Target
Coverage Male
Female Target
Coverage Female
2016
211,600
46%
70,533
36%
141,067
53%
2017
262,200
57%
87,400
45%
174,800
66%
2018
312,800
68%
125,120
64%
187,680
71%
2019
363,400
79%
145,360
74%
218,040
82%
2020
414,000
90%
165,600
85%
248,400
94%
Source: PEPFAR Cote d’Ivoire, 2017

7. Know who you are missing Uganda Clinical Cascade: 15-24 (FY17Q1)
Female
Male
Source: PEPFAR Uganda, FY17 Q1 data

8. Know who you are missing Uganda Clinical Cascade: 25+
Female
Male
Source: PEPFAR Uganda, FY17 Q1 data

9. Geospatial Mapping of all PEPFAR sites : Age and gender patterns in coverage and suppression consistent across districts (25+)
Pockets of poor suppression among 25+ women and men in the east and west/west nile
Viral suppression

10. Age and gender patterns in coverage and suppression consistent across districts (15-24)

11. Zimbabwe National 90-90-90: Known status varies by age and sex

12. Zimbabwe: Age distribution of ART gap, by district, age and sex

13. Evolving testing approaches to reach men

14. Zimbabwe: Positive yield by HIV testing modality, age, and sex

15. Zimbabwe: Volume by HIV testing modality, age, and sex

16. HIV Test Yield by Age, Sex and Testing Modality
This graph clearly indicates that index partner testing and in-patient PITC will identify more HIV positive cases among young people and adult men

17. FY16 results: HIV Testing Models, Yield and Cost Per Positive Case Identified
This graph shows that HIV testing at OPD is the largest contributor in terms of volume and the cheapest model for case identification. Home-based HTC is the most expensive model. As a result, we have decided to significantly reduce the contribution of home-based HTC in COP17 and shift to most efficient modalities such as index partner testing.

18. Adapting clinics to be male-friendly

19. Interventions Targeting Men and Youth
Baseline
Q3 Target
Achievement
Comments
Facility testing n=827
After Hours
15%
30%
165 sites
n=1416 sites
Weekend
19%
35%
224 sites
24 hours
16%
90 sites
n= 205(sites with 24hrs services)
Assisted Partner notification 9%
20%
657 sites
Community (wards) n= 230
Male Focus Group Discussions (FGDs) 1%
10%
93 FGDs conducted
Targeted outreach
(men, years)
68%
80%
* Part of community testing

20. Outreach and Extended Hours – APHIAplus Western Kenya*
Time Interval: Various starts-ups times beginning April and until July Sites: 4 counties: Homa Bay, Kakamega, Migori, Kisumu; 67 Wards; 165 outreach sites Compare to Index testing Yields: Homa Bay 0.9%, Kakamega 6.5%, Migori 3.0%, Kisumu 3.5%
Total all 4 counties
Outreach
Extended hrs.
24 hours
Weekends
Male Female
Male Female
Male Female
No. Tested
8,349
4,673
830
354 53 45
1,987
2,176
No. HIV positive
124
139 15 5 1 28 35
Yield HIV positive (%)
1.5%
3.0%
1.8%
1.4%
0.0%
2.2%
1.6%
Linked 94
108 11 - 26 31
% positives linked
76%
78%
73%
100% _ 0%
93%
89%

21. EVIDENCE of IMPACT of PROGRAM EFFORTS to REACH MEN – LESOTHO, 2017
Unofficial results – Data not verified

22. Expanding VMMC

23. PEPFAR has supported 15.2 million
Voluntary medical male circumcisions
Cost effective one-time intervention
60% relative risk reduction for acquisition of HIV for men
Observational evidence for
protection of women for HIV and STI
Source: PEPFAR Results,

24. Voluntary Medical Male Circumcisions (VMMC)
Reduces the risk of contracting HIV/AIDS by at least 60%
The priority population for VMMC in PEPFAR programs remains men age years 
VMMC benefits women as well: A CDC study showed women who reported a circumcised partner were about 30 percent less likely to have HIV
PEPFAR supported 3.4 million VMMC in 2017 to bring PEPFAR cumulative total to 15.2 million

25. Need for innovative approaches

26. Innovative Solutions to reach men?
Facility-Based Changes: routine testing, after hours and weekend testing, male nurses/healthcare providers, male-only clinic hours
Community-based Mobile Testing
Workplace Testing: target private sector industries (formal and informal sectors) with a high number of male employees
Venue-based outreach (bars, trading centers, churches, schools, sporting events)
Big Data: produce data analytics and products on migratory, behavioral, and consumption patterns for enhanced PEPFAR targeting and impact
Multi-disease wellness programs that involve on-site or mobile testing for other diseases (Hepatitis C, malaria, hypertension, diabetes)
Index Testing
Marketing campaigns designed to use subtle messaging to address risk perception (partner reduction), and increase demand for condoms, testing, and other services
Male targeted incentives
Changing community norms around masculinity through influencers (e.g., church, village chiefs)
Programming for migrant workers

28. Conclusions
HIV and HIV testing (knowledge of status) directly threatened masculinity constructs
Treatment offers promise of restoration to positive masculinity for most of threats
Men identified health as foundation of other core values:
sexuality and procreation
Family
Work
social status
Each value associated with masculinity constructs, specifically agency and strength

29. Concluding thoughts
Thanks to the PHIAs (surveys) & program data, we know:
More than half of men <35 yo do not know their status and are not on treatment – this is fueling the epidemic in the yo women
We are aggressively pursuing new approaches to increase testing in men – self testing and index testing
Increased focus needed to accelerate VMMC progress
Geography – vast difference in HIV prevalence within each country; investments must continue to be targeted for impact
Populations – significant age gap in those we have reached and not reached impacting epidemic control: we have successfully reached women > 25 and men > 35

30. Thank you!
3.4M VMMC in 2017 to bring PEPFAR cumulative total to 15.2 M
Merci!

31. Thank you!