Supporting men living with HIV in South Africa through a peer-led intervention

South Africa still has the largest population of people living with HIV in the world, around eight million individuals, or nearly one in five adults. Despite major progress in access to antiretroviral therapy (ART), the country continues to record about 165,000 new infections and 50,000 AIDS-related deaths each year (UNAIDS, 2024).

While treatment allows people to live long and healthy lives with HIV and is available free of charge in public sector health facilities, a major ongoing challenge is ensuring that people living with HIV start and remain on treatment. Gender disparities in this area are particularly striking. Around 81% of women living with HIV are effectively engaged in care, compared with only 73% of men.

Research shows that most men are aware that treatment works, that it improves health, prevents illness, and stops transmission, yet many still do not start or remain on treatment. The barriers are often psychosocial, rooted in fear and social expectations: fear of stigma and discrimination, of losing friends, partners, or social status, can make it difficult for men to seek help. For many, an HIV diagnosis is experienced as a personal failure or the end to a familiar life, leading to withdrawal and hopelessness.

These challenges are particularly pronounced in KwaZulu-Natal, the province with South Africa's highest HIV prevalence (approximately 23%). It is within this context, and in response to the specific difficulties faced by men, that the Coach Mpilo peer support program was developed to improve the health and well-being of men living with HIV.

Coach Mpilo is a peer support intervention created to help men overcome psychosocial and practical barriers that prevent them from starting or staying on HIV treatment.

The idea is simple but powerful: recruiting men who are openly living with HIV and taking treatment as “coaches” to support their peers. The word “Mpilo” means “life” in Zulu, a fitting metaphor for a program designed to guide men through their health journey, much like a coach would in sports.

The innovation lies in the relational and experiential approach to supporting men who are not inclined to seek healthcare. Coaches receive training on how to build trust, provide emotional support, and help men navigate the healthcare setting and the complexities of living with HIV, including stigma and fear. During the first meetings between coaches and their beneficiaries, the focus is on establishing a relationship, often meeting two or three times to connect personally. Afterwards, contact becomes flexible, through meetings, calls, or messages, adapting to each participant’s needs.

This approach challenges a common misconception found in earlier research on gender disparities in HIV treatment, that men’s lower engagement stemmed from a sense of masculinity, such as feeling “too strong” to seek care or ask for help. In fact, evidence shows this assumption is often wrong. Many men report feeling isolated and afraid after diagnosis, often unable to recall knowing another man living with HIV. The Coach Mpilo model addresses that sense of isolation directly.

The program had already been piloted in different regions of South Africa and had received very positive responses, demonstrating clear demand, most men invited to join agreed to participate. However, there had been no randomized control trials (RCTs) providing rigorous evidence on whether the program works, to what extent, and for whom.

Our evaluation aims to generate robust evidence on the effectiveness and cost-effectiveness of the intervention, evidence that is crucial in a context of domestic and global funding constraints for health programs. We will study the impact of the intervention on men’s health and socio-economic outcomes. With reduced donor support, many clinics have had to scale back their activities, leaving South Africa to take greater ownership of its national HIV response. It is therefore essential for the government to understand the benefits and costs of the multitude of programs that it considers supporting. Understanding whether such an intervention works would represent a major step forward in ensuring efficient use of resources.

Additionally, by studying less commonly measured outcomes, such as improvements in emotional well-being and mental health, we hope to understand whether these benefits could also translate into broader improvement in participants’ lives.

The team is already engaging with the Department of Health and other partners to create awareness about the study and create a platform to share results and discuss future directions. We plan to launch the study during the first six months of 2026. If proven effective, the ultimate goal would be to scale up Coach Mpilo program nationally and integrate it into national HIV programs and clinics, particularly in high-prevalence areas.

In the context of the global funding crisis, combined government investment and external donor support is likely to be important for ensuring that effective treatment support programs are scaled-up. Generating solid evidence from the Coach Mpilo evaluation could also enable organizations that are engaged in HIV service delivery across South Africa to mobilize their own donors and take part in the broader rollout of the program. Providing rigorous and actionable evidence that can strengthen the global response to the HIV epidemic is what our research team is seeking to do in this study.