S Maman 1, MN Kilonzo 2, T Yamanis 3, P Balvanz 1, G Lambert 2, M Mulawa 1, D Conserve 1, L Kajula 2

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1 A A cluster-randomized trial to evaluate the efficacy of a combined microfinance and peer leadership training intervention for HIV prevention with networks of young men in Dar es Salaam, Tanzania S Maman 1, MN Kilonzo 2, T Yamanis 3, P Balvanz 1, G Lambert 2, M Mulawa 1, D Conserve 1, L Kajula 2 1 University of North Carolina at Chapel Hill: Gillings School of Global Public Health 2 Muhimbili University of Health and Allied Sciences 3 American University: School of International Service

2 Formative Research Recruiting men to participate in HIV and gender-based violence (GBV) prevention in sub-saharan Africa is difficult because many are not in school or in a regular place of employment where they could be reached [5]. Our group identified camps, social groups of mostly men, in Dar es Salaam [6]. Camps have average of 32 members & average lifespan of 8 years (range 4-13 years). Camps require membership & have elected leadership. Most members interviewed belong to one camp and visit daily for several hours to socialize in the fixed location. Members supported one another in emotional and more tangible ways, such as providing money in the event of a death in the family. Men in camps reported substantial health risk behaviors. Men s median age of first sex, 16.3 years [7], was lower than the national estimate of 17.7 years, and the proportion who had multiple partners in the past year (47 %) was higher than the national proportion for their age (26 %) [8]. The six month cumulative prevalence of concurrency among sexually experienced youths was 42% [7], substantially higher than other studies of male youth in sub-saharan Africa [8].

3 Pilot Project ( ) We piloted tested a combined microfinance and health leadership intervention with 3 camps and found this approach both feasible and acceptable in these settings. Innovation Leveraged the strong social ties that exist among men in the camps Capitalized on the fact that many camps were engaged in business enterprise and men wanted access to more business training Augmented the natural leadership structure by using it for health promotion Results 22 camp members participated in microfinance 18 microfinance participants (82%) paid back their loans, and of these 15 (83%) received a second, larger loan Loan default reasons included death, chronic health problems, or disappearance 30 camp members were trained as health leaders Conversations between health leaders and peers focused on condoms, sexual partner selection and HIV testing. Few reported conversations about GBV.

4 Current Research Design We are currently conducting a cluster-randomized trial to evaluate the efficacy of the combined microfinance and health leadership intervention in 60 camps in Dar es Salaam. Aim 1: Enumerate and characterize camps where young men at risk for HIV acquisition and transmission socialize in four wards of Dar es Salaam Aim 2: To determine whether men in camps randomized to receive the intervention have a lower incidence of sexually transmitted infections (NG, TV, CT) and report perpetrating less physical or sexual violence against female sexual partners than control camps We will assess the degree to which hope, future orientation, perceived social support, collective efficacy, and social network norms mediate the impact of the multi-level intervention on STI and partner violence.

5 Identifying and characterizing camps We used the PLACE (Priorities for Local AIDS Control Efforts) method to identify camps in four economically disadvantaged wards. Camps were identified through community informant interviews then verified with camp leaders through venue verification interviews. Camp locations were mapped with GPS coordinates and clustered based on proximity to minimize contamination. A random sample of 60 camps were selected in to this trial, half of which will receive the intervention condition. Camps selected from the same cluster received the same condition.

6 Intervention evaluation Behavioral survey at baseline, 12 months and 30 months: Assessing inter-partner violence, sexual risk behaviors, and potential mediators Biological data collection at baseline and 30 months: HIV and STI assessments will be conducted with men Process evaluation to monitor intervention implementation: MFI: Loan uptake and repayment Health Leader: # and type of conversations

7 Microfinance Design We have followed standard principles of microfinance program implementation: Each camp exists as its own loan center and has elected leadership. All eligible camp members participated in a 1-week training course. Loan eligibility requires camp members to form a group of 5 members. When an individual fails to repay an installment, other group members are responsible. Loans are available in 6 or 9 month repayment plans and access to larger loans is available upon successful repayment. Individuals who reach 3 delinquent payments default on their loans.

8 Camp Health Leader Design Camp Health Leaders (CHL) have been trained to be health promoters in their camps. Camp members have nominated individuals who have leadership qualities. Nominated leaders constitute up to 20% of camp s members. CHL training focused on reduction of HIV risk behaviors and gender based violence perpetration, as strategies for communication and social influence. CHLs have been asked to talk with their fellow camp members about HIV and gender based violence prevention strategies CHLs are required to maintain a daily diary to record the number and type of conversations they have with camp members.

9 Study Progress Research progress Camps verified in four wards (n=303) Camps mapped and selected (n=60) Baseline surveys completed (n=1278) Baseline biological assessment completed 74.4% of eligible men (n=389 of 523)provided urine specimens 48.9% (n=256 of 523) provided blood specimens Intervention progress Camp Health Leaders nominated and trained (n=189) Microfinance training complete (n=631 eligible men) Loans distribution in progress

10 Sources Cited 1. UNFPA. Tanzania Country Report Dunkle, K., Jewkes, R., Brown, H., McIntyre, J., Gray, G., & Harlow, S. (2003). Gender-based violence and HIV infection among pregnant women in Soweto. Gender and Health Group, Men on relationships with and abuse of women, Medical Research Council Technical Report, Medical Research Council, Tygerberg. 3. Maman, S., Mbwambo, J. K., Hogan, N. M., Kilonzo, G. P., Campbell, J. C., Weiss, E., & Sweat, M. D. (2002). HIVpositive women report more lifetime partner violence: findings from a voluntary counseling and testing clinic in Dar es Salaam, Tanzania. American Journal of Public Health, 92(8), doi: /ajph Kouyoumdjian, F. G., Calzavara, L. M., Bondy, S. J., O'Campo, P., Serwadda, D., Nalugoda, F.,... Gray, R. (2013). Intimate partner violence is associated with incident HIV infection in women in Uganda. AIDS, 27(8), doi: /QAD.0b013e32835fd Stroeken K, Remes P, De Koker P, Michielsen K, Van Vossole A, Temmerman M. (2011) HIV among out-of-school youth in Eastern and Southern Africa: a review. AIDS CARE-PSYCHOLOGICAL AND SOCIO-MEDICAL ASPECTS OF AIDS/HIV Yamanis, T. J., Maman, S., Mbwambo, J. K., Earp, J. A. E., & Kajula, L. J. (2010). Social venues that protect against and promote HIV risk for young men in Dar es Salaam, Tanzania. Social Science & Medicine, 71(9), Yamanis, T.J., Doherty, I., Weir, S., Bowling, J.M,. Kajula, L,. Mbwambo, J.K., Maman, S. (2013). From coitus to concurrency: sexual partnership characteristics and risk behaviors of year old men recruited from urban venues in Tanzania. AIDS and Behavior. 2013; 17(7), National Bureau of Statistics (NBS) [Tanzania], ORC Macro (2005). Tanzania demographic and health survey