Adaptation and Pre-test of a Shortened Stepping Stones and Creating Futures Intervention Focused on HIV for Young Men in Rural South Africa

"I am now able to open up to other people and receive the services or help I need. Although I haven't received all the help that I need but speaking with other people about my problems relieves me."

Men's engagement in HIV prevention and treatment is suboptimal, including in South Africa. One reason: Inequitable norms of masculinity reduce men's access to HIV treatment and prevention technologies through a range pathways, such as men's unwillingness to acknowledge their vulnerability, limiting healthcare seeking. A common intervention focused on addressing gender-inequitable norms to support HIV prevention and treatment is the Stepping Stones (SS) intervention. Developed in the 1990s in Uganda, it has been used widely with women and men, and evaluations have shown a range of positive outcomes. More recently, SS was combined with a livelihoods intervention called Creating Futures (together called SSCF) to simultaneously address poverty and inequitable gender norms. This paper assesses the process of adapting SSCF to strengthen its HIV content and provide a more scalable (shorter) intervention in rural South Africa. It shares the results of a mixed-methods pre-test of the intervention among young men aged 18-35 years in rural KwaZulu-Natal, South Africa.

Co-adaptation refers to working very closely with those reached by an intervention to adapt an existing intervention. Co-developers were 10 young male peer navigators from the area aged 18-30 years, who were trained in HIV and sexual health promotion and who receive ongoing supervision and oversight. To adapt SSCF, the research team reviewed the current evidence base and worked with the peer navigators to update the SSCF theory of change (ToC) and manual. The ToC sought to describe how the structural challenges young men faced shaped young men's lived realities, and how SSCF impacted on these to reduce men's perpetration of intimate partner violence (IPV) and their alcohol use and to strengthen livelihoods. The peer navigators raised two issues that were not in the initial ToC. The first issue was their use of traditional healthcare systems as an alternative to biomedical healthcare; the second was the lack of networks within the community and outside of it, and how this impacted on their economic opportunities. These issues were integrated into the ToC.

The revised intervention was ~45 hours (9 sessions) as opposed to ~63 hours and included a greater focus on HIV prevention and treatment technologies. It was designed to be delivered to between 10 and 20 young men at a time, using small group participatory activities. All intervention participants were issued with slips providing information on how to access mobile clinics (e.g., through sending a message requesting a call-back), and slips with QR codes linked participants to their data. Participants were also shown the mobile clinics, and a nurse explained the process and care provided.

Of the 60 men who agreed to participate in the intervention, uptake (attending one session) was n = 35 (58%) and retention (attending 6 or more sessions) was n = 25 (71%). There was some suggestion that uptake and retention in the intervention was better among those recruited via peers, rather than through random selection. Two (6%) of participants who attended at least one session of the intervention went to a mobile clinic within two months of receiving the intervention. In addition, two men tested for HIV and then underwent voluntary medical male circumcision (VMMC).

Participants who were interviewed said they found the approach of SSCF acceptable. They described the intervention's focus on discussion and open debate as something that was different from what they had experienced in previous health interventions (i.e., didactic lectures instructing men what to do, rather than allowing men to speak freely). Young men appreciated that SSCF was delivered by someone young, who was like them, and they were actively engaged in debates about things relevant to their lives. Despite men liking the intervention, some did struggle to attend all sessions due to competing work demands.

The qualitative data also broadly supported the intervention ToC, including the normalisation of HIV in men's lives and the importance of health for men in achieving their life goals. For instance, men often see HIV as a threat to their identity, and there was some evidence that participation in SSCF supported men to see HIV as one of many challenges they faced in life, rather than "the" challenge. In the context of this project, men were able to access youth-friendly mobile clinics; one participant who went to the mobile clinic, described a very positive experience, even after testing HIV positive. There was also some evidence that SSCF supported increasing men's knowledge about HIV prevention technologies, specifically pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), though men typically did not seek out PreP for themselves.

"One challenge was that while many participants qualitatively reported testing for HIV using self-test kits, there remained a reluctance to access clinics for confirmatory testing amongst those who were negative. This was partly linked to assumptions about clinics being curative, rather than preventative, spaces. As such, strengthening young men's recognition of health clinics providing prevention (and not only cure) would be an important strengthening of this approach. It may also have been ongoing fear of clinics or continued masculine assumptions of only seeking treatment when sick..."

The data also highlighted the need to focus more on HIV-related stigma and fear and on the importance of HIV self-testing kits in encouraging testing. In response, the research team revised the ToC and manual to incorporate a more explicit focus on the trauma of HIV and ensuring HIV self-testing and the provision of HIV self-tests. The research team also included an ongoing WhatsApp discussion group.

In conclusion: "The modified SSCF intervention focused on addressing challenges related to men's engagement in the HIV prevention and treatment cascade through addressing gender inequitable masculinities and health systems barriers, was promising, with qualitative and quantitative data broadly supporting that the intervention was acceptable and the qualitative data supported the broad mechanism of change and the underlying ToC....Evaluating whether the modified SSCF intervention supports men to change their behaviour around HIV-prevention and -treatment over multiple years is a critical outstanding question."