Nigeria has a population of approximately 140 million people with a current adult HIV prevalence of 4.4% in 2008 and about 3 million individuals living with HIV in Nigeria. The HIV epidemic in Nigeria has been recently described as "generalised", spreading from the high risk to the general population. The most-at- risks-populations (MARPS) continue to serve as "reservoirs" and bridging populations of the HIV infection, thereby fuelling the epidemic in Nigeria. This group includes female sex workers (FSW), men that have sex with men (MSM), injection drug users (IDU), long distance truckers, uniformed professionals, etc.

The 2007 IBBSS shows varied overall HIV prevalence among MARPS with MSM having the second highest prevalence of 13.5% (25% in Lagos) compared to 25% among FSW. MSMs are particularly a high risk population in Nigeria. The MSM community is socially stigmatized, and receives scanty services to promote healthy sexual behavior and HIV/STI prevention. In Nigeria, nearly all informational education messages focus on heterosexual transmission of STI/HIV, and MSM are not sensitized to their own risk for contracting an STI. In addition, health professionals are largely unaware of their special needs. It is therefore paramount to include MSM in programs to prevent HIV/AIDS, since they are at high risk for HIV/STIs but are historically ignored by prevention campaigns and limited in their access to sexual health services. Other predorminantly male occupations eg transport workers, uniformed professional, male clients of female sex workers, etc were also highlighted by the IBBSS 2007 as having HIV prevalence above the National figures. Same sex practices are also reportedly prevalent in about 10% of these groups of men.

The Population Council, through this project, seeks to avert new HIV and sexually transmitted infections (STIs) among these men engaged in multiple, concurrent or serial sexual relationships, and those who engage in high-risk sexual practices such as unprotected vaginal and/or anal sex with their male and female partners. We will accomplish this by utilizing a social franchise model to make quality medical care accessible to all men in a hassle-free manner by engaging both public and private sector service providers. This strategy will improve knowledge of risky practices among these men, reduce high-risk sexual practices, reduce barriers to HIV/STI detection and treatment, modify care-seeking behaviors, and promote individual and group assistance through supportive social networks. At its core, this strategy will identify clinicians in private practice in key Nigerian cities and towns and engage them through trainings and continuing medical education (CME) efforts to provide non-discriminatory and appropriate sexual health care for men-at-risk including HIV testing & counseling (HTC), sexually transmitted infection testing and syndromic management (STI-SM), pre-packaged therapy (PPT) for STI, condom/lubricant distribution and referrals to existing services appropriate for the individual's needs. We will also use an online training approach as a CME strategy to train participating clinicians and laboratory staff on good laboratory practice (GLP) and quality diagnosis and treatment of opportunity infections (OIs).

The project focusing on high risk men and MSM, incorporated into a larger sustainability strategy, the Men's Health Network Nigeria (MHNN), will provide a comprehensive package of information, education and communication activities to bring about behavior change, change community norms, improve access to and quality of HTC and STI services, and reduce vulnerability and risk among men engaged in high- risk practices. In addition, it will provide appropriate referrals to MHNN physicians who will in turn provide comprehensive sexual-health clinical services. The project will support social networks of high-risk male subgroups including men who have sex with men (MSM), injection drug users (IDU), transport workers and uniformed military men as same sex and high risk sexual practices occur in a significant proportion among these target groups. This strategy will allow direct intervention to men known to be at high risk and will take advantage of existing structures to improve access to health services and ultimately HIV/STI related prevention and treatment services. As a result, we anticipate that risky sexual behavior will decrease and the opportunity for men to adopt appropriate sexual health behaviours, particularly HIV prevention strategies will increase. Men who test positive or present as HIV positive and who need HIV care and support will be referred to services through existing HIV care and treatment providers.

As MHNN expands, incorporating other high risk groups engaged in same sex relationships such as institutionalized settings, we will target military families and communities around army barracks. Messages such as partner reduction and Men as Partner's will focus on the adult male population. Other messages will include importance of VCT, safer sex interventions and approaches aimed at the entire family. Gender specific out of school Safe Space Youth Groups (SSYGs), and event-based activities will

be developed for adolescents, with a focus on delaying sexual debut for younger children and age- appropriate sexual and reproductive health messaging for older adolescents (including marriage delay messages).

The MHNN project had been rolled out in three (3) cities; Abuja (FCT), Lagos and Ibadan (Oyo) (including the transport corridor along Lagos-Ibadan express way) starting from COP08 and will expand to three more cities: Calabar, Kano and Kaduna and further to meet needs of high risk men in high prevalence areas in COP10. This project targets most-at-risk population of men including men who have sex with men (MSM), injection drug users (IDU), transport workers and uniformed military men.

The MHNN social franchising approach will employ KOLs to interact and engage groups whose members are known to engage in high-risk sexual activity, i.e., MSM and transit workers. In addition to engaging these men for the purposes of providing HIV prevention messages, we will also provide referrals to medical clinics for HIV testing, TB screening and STI syndromic diagnosis and treatment. These clinics will be pre-screened to ensure that providers are comfortable treating and interacting with men with high risk behaviors, particularly MSM, and that they are comfortable discussing appropriate risk-reduction measures with these men. The MHNN recognizes that male health seeking practices among sexually active men are limited to only a few complaints, with sexual dysfunction and STIs being the most prominent. By using principally private sector providers as the entry point, MHNN will allow high risk men to bypass the public sector, in which non-discriminatory care can be elusive.

Procurement of medical commodities will, as much as possible, be sourced through the PEPFAR Nigeria procurement mechanisms as a cost saving effort. We also envisage that lessons learnt within the inception phases of the MHNN project will guide expansion to other cities in COP10. As a result, duplication of costs will be minimized especially by seeking to organize joint trainings with other PEPFAR implementing partners. The project will also seek to leverage resources from the Government of Nigeria through NACA and NASCP especially in areas of technical persons for trainings, provisions of condoms and HIV test kits were necessary.

In order to measure the progress and attainment of the program, the intervention established baseline values with extracts from the IBBSS 2007 and initial interactions with the target communities. The progress of the project will be monitored on an on-going basis with routine service data tools and evaluated in COP10 (third year of the project) with structured and tested tools to measure outcome and impact against baseline. This results of this evaluation will help to strenghthen program strategies and make necessary adjustments.

Long term sustainability of the project will be ensured through the development of a multi-donor social franchising model, the "Men's Health Network Nigeria" which will spin off as an institution of its own.

This activity is on-going in 3 sites - Abuja (FCT), Lagos and Ibadan (Oyo) (including the transport corridor along Lagos-Ibadan express way) and will be extended to 3 more sites (Calabar,Kano and Kaduna) during COP10 project activity year. It is designed an an HIV prevention activity consisting of several inter-related components: 1) To promote abstinence and fidelity for male adolescents with abstinence messages, and target men with "be faithful" messages, as part of a comprehensive male involvement curriculum addressing homophobia and violence. 2) To increase demand for and availability of condoms/lubricants and other prevention activities including STI management to high-risk men and their male and female partners; 3) To provide clinic and community-based HIV testing and counseling (HTC) to men in a culturally and gender-sensitive manner; 4) To support a network of key opinion leaders and peer educators to reach their peers and refer them to service providers.

The HCT component of this intervention will include: provide clinic and community-based HTC to high

risk men, including MSM, Transport Workers, Injection Drug Users and Uniformed Professionals in culturally and gender-sensitive manner: 18 clinics will provide confidential HTC to clients; 3,500 clients will have be tested for HIV using nationally approved HIV rapid testing algorithms and received their results; and 24 counselors will be trained in local languages in confidential counseling and testing using the National HTC training curriculum. In addition, the project will provide technical assistance to support 2 networks of advocates around MSM service delivery for strategic information activities, as well as 8 individuals receiving training in strategic information (covered through other funding sources). This includes training in monitoring and evaluation, surveillance, and/or health-management information systems. QA/QC will be performed among public and private laboratories affiliated with the project, though no direct laboratory funding is provided under this grant.

Population council intends to pilot a Computer-Assisted Self Interviewing (CASI) method to aid efficient delivery of HTC services from other funding sources. The HTC component to this program provides a vital linkage to onward referral services for HVOP program areas, specifically for men engaged in high risk practices, and serves as an essential gateway for linked/clustered services under the Global Fund strategy of clustered providers for STI treatment, ART, and care and support. Access to quality condoms and lubricants as well as STI syndromic management and other health services will improve through the establishment of men-friendly network of healthcare providers. In COP10, three public/private sector clinics will be selected and shaped into men-friendly clinics.

Policy-level interventions are not specified in this activity; however significant engagement with Government of Nigeria (NACA, NASCP) is on-going and will be intensified in COP10 essential steps to gradually move forward with a public health focused rights-based agendas to support protection of services to high risk and hghly stigmatized groups such as MSM and IDUs.

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