In Africa, HIV prevention has been most successful with women, not men. For example, young, South African men aged 18-29 years continue to have a high incidence of HIV, frequent drug use, low HIV testing rates, concurrent sexual partnerships, and low rates of HIV testing and utilization of medical care. Innovations are needed in how, when, and where we engage men in HIV prevention. With R34 funding, we successfully demonstrated the feasibility of engaging young men with soccer and vocational training to reduce drug use. We randomized two neighborhoods to either: an intervention (soccer and vocational training contingent on behaviors at soccer); or a delayed-delivery control neighborhood. Almost all eligible neighborhood men were recruited (95%; N=142) and 90% reassessed at 6 months. In the intervention condition, 80% of young men regularly attended soccer and 55% earned entry to vocational training. Intervention men completed drug tests at soccer (with uptake rising over time and drug use decreasing), and increased employment over six months, compared to control men. HIV testing did not increase, based only on self-reports. Qualitative interviews of men, coaches, and family members demonstrated the program's benefits in shifting men's role in their homes and communities, although attitudinal shifts towards women were minor. Based on these results, a randomized controlled trial (RCT) is proposed to test the efficacy of randomizing all young men in a neighborhood to receive: 1) soccer training (8 neighborhoods, 400 men); 2) soccer and vocational training (8 neighborhoods, 400 men); or 3) a control condition (8 neighborhoods, 400 men). The primary outcomes will be decreased substance use (tested with rapid diagnostic tests [RDT]), increased repeat HIV testing (linkage, retention, and adherence to medical care among HIV-infected men), no concurrent partnerships, increased condom use, and no violence/arrests. Stellenbosch University interviewers will conduct assessments at recruitment, 6, 15, and 24 months (using mobile phones). Coaches will implement a Life Skills manual, as well as integrating cognitive-behavioral skills into problem situations that arise at games/practices, and reporting in real time via mobile phones all intervention contacts and content. Qualitative interviews will be conducted with coaches and young men (n=30 at each 6 month interval). If the RCT is successful, global program diffusion is probable by the Fdration Internationale de Football Association (FIFA) with national funding by the South African government NEET (Not in Education, Employment or Training) vocational training program, whose annual funding is typically underspent.
Global donors have consistently prioritized HIV prevention (e.g., perinatal focus) and microfinance among women, not men, due to men's alcohol and drug use. This project aims to tailor an HIV program for men, aiming to create demand for the intervention, rather than having to sell the program to men, which is especially important as combination prevention strategies have increasingly focused interventions in health care settings, an underutilized service by men. This project builds on two priorities for men: soccer and employment; if successful, this project can help us redirect preventive interventions for men.