Addressing Uptake of HIV Testing and Linkage to Care Among Men in Côte d'Ivoire: An Evaluation of the Brothers for Life Program Implementation.

BACKGROUND: Historically, men in sub-Saharan Africa have worse outcomes along the HIV care continuum than women. Brothers for Life (BFL) is a community-based behavior change intervention for men, adapted for Côte d'Ivoire, involving group discussions that address salient gender norms and promote HIV prevention, testing, and linkage to care with support from peer navigators. The goal of this study was to describe the BFL program as implemented in Côte d'Ivoire, evaluate program implementation, and report uptake of HIV testing and treatment among BFL participants. SETTING: Three urban and periurban sites in Côte d'Ivoire. METHODS: The implementation evaluation assessed the fidelity and acceptability of the BFL program and the reach of program completion, testing and peer navigation using qualitative and quantitative approaches. RESULTS: BFL facilitation fidelity and content fidelity were high. Semistructured interviews with BFL participants indicated that men appreciated the format and content and that the BFL program helped some participants overcome their fears and adopt more positive attitudes and behaviors around testing and treatment. Assessments of reach showed that, of the 7187 BFL participants, 81% tested for HIV as part of BFL and 2.3% (135) tested HIV-positive. Of those, 76% (102) accepted peer navigator support, and 97% (131) initiated treatment. After 6 months, 100% of the 131 men who initiated treatment remained in care. CONCLUSION: The implementation of BFL in Côte d'Ivoire successfully achieved the goals of engaging participants in discussions around HIV prevention, encouraging HIV testing, and achieving linkage to care, treatment initiation, and retention.

Bringing fear into focus: The intersections of HIV and masculine gender norms in Côte d'Ivoire.

This qualitative research study explored the role of masculinity in men's engagement in the HIV care continuum in Côte d'Ivoire. The researchers conducted 73 in-depth interviews and 28 focus group discussions with 227 Ivoirian men between November and December 2016 across three urban sites. Participants in the study expressed that fear was the primary barrier to HIV testing and treatment. These men described five value domains-health, sexuality, work and financial success, family, and social status. Men saw HIV as a direct threat to their agency and strength with respect to each of these value domains, thus shedding light on their reluctance to discover their HIV status through HIV testing. With this data, the researchers created the Masculine Values Framework, a descriptive framework of masculine values that can be applied to better understand the behavior men exhibit in Côte d'Ivoire in the face of HIV. The Masculine Values Framework offers practical guidance for developing gender-sensitive HIV-focused social and behavior change programming in Côte d'Ivoire and similar contexts to reach the UNAIDS 90-90-90 targets.

"You Take Medications, You Live Normally": The Role of Antiretroviral Therapy in Mitigating Men's Perceived Threats of HIV in Côte d'Ivoire.

Men diagnosed with HIV face gender-related barriers to initiating and adhering to antiretroviral therapy (ART). This qualitative study (73 in-depth interviews; 28 focus group discussions), conducted with men in three urban sites in Côte d'Ivoire in 2016, examined perceptions of ART, including benefits and challenges, to explore how ART mitigates HIV's threats to men's sexuality, economic success, family roles, social status, and health. Participants perceived that adhering to ART would reduce risk of transmitting HIV to others, minimize job loss and lost productivity, and help maintain men's roles as decision makers and providers. ART adherence was thought to help reduce the threat of HIV-related stigma, despite concerns about unintentional disclosure. While ART was perceived to improve health directly, it restricted men's schedules. Side effects were also a major challenge. Social and behavior change approaches building on these insights may improve male engagement across the HIV care continuum.

Men's perceptions of HIV care engagement at the facility- and provider-levels: Experiences in Cote d'Ivoire.

Men in sub-Saharan Africa have lower rates of HIV testing and are less likely to initiate treatment compared to women. Service delivery dimensions are a key factor in facilitating engagement along the HIV treatment continuum for men and women, yet male specific overall perceptions of the service delivery environment have received little attention in West Africa. This study draws on qualitative data collected in Côte d'Ivoire to explore provider-level and structural factors affecting men's engagement in HIV testing and treatment through interviews and focus group discussions conducted with health workers and men living with HIV (some on ART) or whose HIV status was unknown. Factors influencing decisions to test or initiate treatment were considered in terms of perceived benefits and costs. Men described costs at the interpersonal (client-provider) level, such as unwanted disclosure or stigma, which were weighed against the potential for social support and clinical guidance. Likewise, fear of unwanted disclosure operated at the facility level, as the layout of facilities sometimes grouped clients living with HIV together. Notably, the benefits men described from engaging in HIV testing and care all operated at the interpersonal level and none at the facility level. In light of the fact that provider- and facility-level factors influenced the perceptions and experiences of men along the treatment continuum, we offer recommendations to reduce barriers to testing and engagement in care related to service delivery.

Perceptions matter: barriers to treatment of postpartum hemorrhage.

Postpartum hemorrhage is the leading cause of maternal deaths in developing countries. This report highlights the social and cultural factors that influence the decision to seek care in cases of postpartum bleeding. Survey data on awareness of danger signs in the postpartum period and findings from the anthropologic literature describing beliefs about bleeding in childbirth and the postpartum period are presented. Findings point to a mismatch between actual and perceived risks of danger in the postpartum period. This may reflect a viewpoint that there are few risks remaining after the baby is born. This may, in turn, shape the perception that the postpartum period is one in which less vigilance is required compared with labor and birth. Such beliefs are important to consider, as they may influence timely seeking of emergency obstetric care. Efforts to reduce the incidence of postpartum hemorrhage as a major cause of maternal death must progress on two fronts: on the supply side to ensure the provision of skilled care and on the demand side to ensure that women and their families accept the view that bleeding after birth is dangerous and that skilled care is preferable to traditional care.