A peer-led intervention to promote engagement in HIV care for men living with HIV in South Africa

HIV remains a major global public health challenge, with 39 million people living with the virus in 2022 (UNAIDS, 2022). Sub-Saharan Africa is the most affected region, and South Africa has the highest number of people living with HIV, with 7.8 million cases in 2022 (UNAIDS, 2022). Despite progress in expanding access to antiretroviral therapy (ART), significant gender disparities remain: around 80% of women living with HIV are on antiretroviral therapy, compared with only 68% of men (UNAIDS, 2022). Over 30% of HIV-positive men are not engaged in care (Dovel et al., 2016), contributing to higher HIV-related mortality among men and increasing the risk of transmission to women.

Retention in HIV care is a persistent challenge. Interruptions can result in viral rebound, higher transmission risk, and poor health outcomes. Common barriers include side effects, psychological distress, stigma, logistical challenges, and socioeconomic constraints. Evidence shows that peer-led interventions can improve ART adherence and retention, increasing engagement in care and viral suppression among men living with HIV (Berg et al., 2021).

Coach Mpilo is a peer-support program specifically designed to help men initiate and adhere to HIV treatment. Developed in partnership with Population Services International (PSI) and supported by the Bill & Melinda Gates Foundation and other South African partners, the intervention uses male peers, openly HIV-positive and fully adherent to antiretroviral therapy, as “coaches” to provide personalized support.

The current evaluation will take place in six primary healthcare facilities in KwaZulu-Natal, the province with the highest HIV prevalence in South Africa. Participants will be randomly assigned to either standard care alone (control group) or standard care plus coaching (intervention group).

The study will also collect data to understand why some men may not benefit fully from the intervention. A cost-effectiveness analysis will inform national HIV investment strategies and policy decisions.

Through the Coach Mpilo intervention, the project aims to:

1. Improve retention and adherence in HIV care: Increase the proportion of men who stay engaged in care at 12 months, consistently attending follow-up visits, maintaining antiretroviral therapy supply, and achieving viral suppression at six and twelve months.
2. Identify subgroups needing additional support: Understand which men do not fully benefit from coaching to adapt interventions for specific needs.
3. Demonstrate impact and scalability: Assess cost-effectiveness and provide evidence to support the scale-up of Coach Mpilo and inform related policy and funding decisions.