Because men equate illness or attending health services with weakness, many defer seeking health care until it is too late. When they do seek help, they often feel unwelcome at health facilities, which are largely designed for women. Frequently they confront health workers who are uncomfortable treating them because they have not been trained to do so, are concerned that men's services will be too time consuming, labor intensive, and too expensive to provide, are afraid that men will be threatening or disruptive, or are simply unaware of the factors that attract and repel men.

EHSA and partners will implement a comprehensive supply and demand program at the MAP Centre, including HIV counseling and testing (mobile drives and community testing at the MAP Centre), Couple Counseling, CD4 testing, basic STI and primary health checks services. On the supply side, the project team will work with health workers and sites to address organizational and attitudinal barriers that deter men from using services. Through training, EHSA will build health workers' capacity to attract men to use services themselves and to support their partners' attendance. EHSA will also train health workers on counseling and communicating with men about HIV, both alone and with their partners.

EHSA will also provide teachnical support to other prevention partner through it mobile VCT and health van through drives in communities and support to other grassroot communities, individuals, NGO and CBO. The Van and sites will include locally appropriate male-friendly initiatives, such as displaying HIV BCC materials that appeal to both men and women, scheduling services at times that fit men's work and recreation patterns, providing opportunities for men and women to attend as couples, and involving men in planning, implementing and evaluating services.

MSM and injecting drug users (IDU) have special health and counseling needs. Due to denial of their existence in especially in the rural communities: EC, LP and the severe stigmatization of their behaviors, however, they are unlikely to get the help they need. To increase health workers' awareness, and to help them provide non-discriminatory care, health worker training will include a brief overview of sexual orientation and the social factors that influence people to start, and to continue using, illicit drugs. Training will include a brief discussion of these men's special health needs plus information on where to refer men for specialized care. As required, EHSA will link with other specialized programs, such as Men's Clinic, to arrange more intensive training for health workers who need it. .

Male Circumcision (MC) is now recognized as one of the most promising HIV prevention approaches when integrated with all other HIV prevention, care, and treatment strategies. South African stakeholders believe that community acceptance of MC should not be imposed. EHSA through the MAP Center will work closely with the provincial department of Health and the department of Social Development to determine how to promote male circumcision for HIV prevention in MAP workshops, health worker training, focused group discussions, door-to-doors and community mobilization activities. EHSA will link interested partners with the Male Circumcision Working group in SANAC, to train health workers in clinical MC services including modern surgical technique.

EHSA will work with community groups and outreach workers to increase men's demand for services via existing community mobilization activities and mass media campaigns, and through new specific activities by community outreach workers. In addition, MAP workshop participants will discuss the factors that deter men from using specific services and will examine the importance of seeking help when it is

needed. Throughout its work, EHSA will promote messages that equate men's use of HIV services with manhood, strength, and courage. EngenderHealth is committed to effective project monitoring and the use of data for planning and decision making. To do this, EHSA program team will be involved with the monitoring of this project: determining meaningful indicators; reporting on specific indicators; reviewing indicators and data results; and applying results to planning, course correction and decision making.

To avoid duplication and to minimise time and expense, EHSA will exploit existing information and data collection systems used by USAID/ PEPFAR and gender partners and SA government Agencies. The Project Team will set up a comprehensive system for routine performance monitoring that will function in coordination with health management information system. along with its District Health Information System (DHIS). We will also coordinate all our M&E efforts with USAID, in collaboration with their other HIV/AIDS and gender projects.

EHSA's M&E Program Officer will manage performance monitoring under the direction of the COP. Once the PMP is finalized and approved, the team will work closely with the partner to assure the quality of data collection, interpretation of findings, and integration and the use of data for planning and decision- making..

The PMP will cover the project, and will include the data collection process for establishing baseline conditions, the key indicators against which progress will be measured, and the data collection process for the mid term and final evaluations.

All components of this Project will monitor their performance. Therefore, responsibilities for M&E will be shared among the Prime and other partners, under the coordination of the M&E program Officer. The Table below outlines illustrative M&E activities per component. As needed, and in a timely manner, survey tools, questionnaires, and databases will be developed by the EHSA team for use on this Project. To ensure quality collection and reporting, EHSA will develop the capacity of local partners as needed to monitor and report their activities through training, follow-up, feedback, and participatory planning and implementation. EHSA will implement a quality assurance (QA) system to monitor data recording and reporting, and will provide assistance as needed to implementing partners to improve their own QA systems. Data audits will be done every quarter for the first year and every 6 months thereafter using an audit checklist.

EHSA will identify and carry out selective targeted investigations driven by programmatic need and NSP priorities, in consultation with other partners.

Baseline survey reports will be produced and disseminated to stakeholders. Each quarter, project data will be collected, consolidated, analyzed and disseminated to stakeholders, including implementing partners, collaborating organizations, and program staff. Relevant project documents will be posted on EngenderHealth's public webpage.

In collaboration with its partners, EHSA will identify and document success stories of initiatives that are successfully engaging men, and will disseminate the findings widely through the MenEngage SA and EngenderHealth public websites, professional literature, and local and international meetings.

EHSA will provide USAID/PEPFAR with printed and electronic copies of all program products, including publications, studies, trip reports, assessments, and short term consultancy reports.

Gender norms—societal expectations of men's and women's behaviors are among the strongest factors fueling HIV transmission worldwide. Traditional male gender norms encourage men to equate a range of risky behaviors—using violence, substance abuse, pursuing multiple sexual partners, dominating women, alcohol and drug abuse—with being manly. Rigid constructs of masculinity lead men to view health- seeking behaviors as signs of weakness. Men who adhere to non-equitable views of manhood are more likely to participate in unsafe sexual practices, act violently towards women, and engage in substance abuse. In addition, women's low status limits the social, education and economic opportunities that help protect them from infection.

In South Africa, multiple sexual partners are socially condoned and often encouraged for men. 20% of youth believe that a man must have more than one partner to be sexually satisfied, while over 30% believe it is impossible for men to have a sexual relationship with only one woman at a time. 10% of currently married women and men are in polygynous unions2. Long term concurrent relationships, as polygynous marriage, can rapidly transmit HIV if any member of the sexual network has outside partner(s). More than a quarter of sexually active men report having two or more partners in the past twelve months, but only half used condoms at last sex with their non-spouse.

Only 4% of men report having sex with a prostitute in the last twelve months (although there are regional and occupational variations), however, other forms of transactional sex are frequent. Gift giving is a standard component of sexual relationships among youth. Peers and family sometimes urge young women to exchange sex to gain financial security. Such relationships create clear power imbalances that

increase women's vulnerability to HIV. Economically dependent women are less able to negotiate for safer sex, including consistent condom use, and this dynamic is further complicated when there are significant age disparities between partners.

Violence also reflects the power imbalances between men and women. In a Dar Es Salaam study , 8.5% women reported being forced to do something sexual with an older person before age 12. In their lifetime, 45.7% had one or more verbally abusive partners, 37.6% had one or more physically abusive partners, and 16.3% had one or more sexually abusive partners. 11.4% experienced at least one physically violent event during the past three months. The connection between HIV and gender-based violence is clear. Alcohol use fuels HIV transmission by reducing inhibitions to engage in high-risk sex such as unprotected casual sex, sex with sex workers, and sex with multiple partners. Alcohol abuse also increases domestic violence. For PLHIV, alcohol can further suppress the immune system, speeding the onset of AIDS and related illnesses. Men of all social classes are encouraged to drink and they often seek status based on the amount of alcohol they can consume. Alcohol consumption, however, is highest in poor communities where potent home-brews are cheap and readily available.

All of these behaviors are rooted in traditional male and female gender roles and expectations. Successfully redressing these harmful beliefs and practices through transforming South African men, women and social structures, therefore, is critical to bringing the country's HIV epidemic under control.

The goals of the integrated behaviour change model are to: • Promote partner reduction and fidelity and reduce high-risk behaviors; • Promote supportive social norms that discourage multiple partnering, violence, and sexual coercion; • Promote positive health-seeking behavior by men, including male participation in health services and in the national HIV response. • Improve access to RH, HIV, and psycho -social support services in the 3 provinces; the Eastern Cape, Limpopo and Gauteng.

Through MAP Centre situated within grass root communities, EHSA will transform male gender roles in three primary ways: • Promote gender norms that portray men as supportive partners. Men will understand that masculinity can best be manifested through protecting the health and well-being of their spouses, lovers, and children. • Promote gender norms that portray men as clients of clinical HIV services. Traditional concepts of masculinity reinforce the idea that men should not seek health care. By transforming these norms, men will associate health seeking behaviors with courage and strength. • Transform gender norms regarding men as agents of social change. Men will realize that real men

actively stand for gender equality and against gender-based violence. Men will appreciate that they have the power to change societal norms and that there are significant benefits in doing so, for themselves and for the women and children in their lives. • Integrate and provide all above interventions as a comprehensive service to communities, individuals and organizations.

Transforming gender roles requires large scale societal change. From birth, humans are socialized to adopt gender roles by a range of influences. EHSA, therefore, will work through multiple levels of society. MAP's ecological model addresses multi-faceted aspects of the social environment to effect personal and social change. They include strengthening individual knowledge and skills, creating a supportive peer and family environment, increasing men's use of health services, mobilizing communities, changing organizational practices, and reforming policy and legislation.

Through this comprehensive approach, EHSA will contribute to PEPFAR 7 and 10 goals, USAID's Health Sector and Strategic Plan for Africa goals, and to the Millennium Development Goals in Health. Respond to priority number 1 of the South Africa National strategic plan 2007-2011. In order to create sustained behavioral change, studies have identified the importance of men undergoing a personal reflection process that increases their understanding of how existing gender norms negatively affect their own lives, their partners and their families. EHSA will work with local and international organizations including schools, NGOs, CBOs, FBOs and workplaces to help individual men understand how current gender and social norms increase their personal and their partners' risk for HIV and how they can adopt and promote alternate, healthier behaviors. Through ongoing experiential workshops, dialogues and focused group discussions.

Through group workshops that are rooted in social learning theory, use youth and adult learning principles, and are participatory; non-directive approach, participants will reflect on their personal values concerning gender. The initial sessions examine traditional gender roles, stereotypes and the power dynamics between men and women. With a gender framework in place, the group focuses on men's willingness to protect themselves, their partners and their families from HIV, emphasizing abstaining from sexual activity, reducing multiple concurrent partnerships, increasing fidelity, and eliminating inter- generational sex, sexual coercion and violence. Finally, activities encourage participants to seek voluntary counseling and testing, to take an active stand against violence and HIV-related discrimination, and to help care for and treat those who are infected. In each workshop, participants will develop action plans that indicate how they will support a community response to HIV and gender norm transformation. EHSA aimes to focus it behaviour and integrated approach in 3 provinces working with a total of 12 schools in FY2010; 6 business (SME and large organizations); out-of school youths and adults in the above provinces. Building on the excellent relationships that EngenderHealth, SPW and local

government departments and clinics; EHSA will orient an extensive and diverse group of partners to the MAP approach through individual meetings and through national, provincial, district and local orientation workshops.

The MAP Centers will adapt and use EngenderHealth's Men as Partners? curriculum, which has been implemented in more than 20 countries, including South Africa, Kenya, and Uganda. Core staff from collaborating organizations will provide input to curriculum adaptation, including issues specific to South Africa such as male circumcision, raising awareness of illicit drug use and same sex behavior, and strategies for working with women to transform their views of male gender roles. They will also help develop associated materials for individual and group education work. Following approval of all materials by Health and Welfare SETA and USAID, EHSA will translate the materials into Xhosa, Zulu, Sotho and Pedi.

EHSA staff will work with each collaborating partner and individual to identify their unique Individual/ technical assistance needs, and to select motivated staff and volunteers to lead MAP group education. EHSA staff will guide these leaders to develop detailed strategies and implementation plans, which will include a range of training and post-training mentoring, supervision and follow-up activities. EHSA will train core staff from each partner organization as MAP master trainers. TOT training includes gender values clarification, extensive orientation to workshop activities, and repeated practice and feedback on facilitating training sessions. EHSA will support the master trainers to train other facilitators within their organizations. EHSA will follow-up to ensure that training is appropriately and efficiently implemented according to each organization's implementation plan. To assure quality, EHSA staff will attend MAP workshops conducted by the organizations' trainers at least quarterly to provide on-the-job coaching. To improve the master trainers' own supervision skills, EHSA will train them in Facilitative Supervision?, an EngenderHealth curriculum that emphasizes mentoring, joint problem solving and two-way communication. Annual refresher workshops will include recent MAP methodology developments, training needs expressed by the trainers and collaborative partners, and issues arising during the follow- up visits. When challenging harmful social norms, power lies in numbers. Most men are good men who want to eliminate violence and other negative male behaviors, however, they are unsure of what they can do and lack the opportunity to act in solidarity. The MAP Community Engagement Manual, recently revised and piloted in Uganda is essential for communities while the SCAGE manual will be applied to schools for in- schools youths.

EHSA will support schools education structures and collaborating partners to conduct participatory in- school and community-based needs assessments to identify factors that drive men and boys to take health risks including alcohol and drug abuse, the reasons for violence against women in their

community; and community perspectives on practical ways to rectify these problems. EHSA will help partners incorporate the information gained into MAP training and community mobilization activities.

EHSA will put together action kit to include personal testimonials from men and boys who are working in their communities and schools to transform gender norms, promote gender equity, eliminate gender- based violence, and address HIV. MAP Centers will employ digital storytelling, a powerful, innovative multi-media format that combines voice, photographs and music in 3-minute video stories. EngenderHealth has pioneered digital story CD compilations in India and South Africa (www.engenderhealth.org/ia/wwm/wwmds.html and www.engenderhealth.org/ia/wwm/wwm-india.html ). EHSA will invite men to share their stories, and train them in video production. EHSA will use the videos in MAP workshops, community events, radio, television, national advocacy meetings, and local and international conferences. The kit will include a digital stories facilitators' guide to help partners use them most effectively. Sporting events attract men of all ages. Sports clubs and informal soccer teams draw in adolescents and younger men. EngenderHealth's S-CAGE Initiative in South Africa works in partnership with a global organization, Grassroots Soccer, to integrate gender norm programming in their soccer and life-skills based curriculum. EHSA will work with groups such as Show Me Your Number to integrate gender transformative life skills programs into soccer clubs. Further building on men's interest in sports, EHSA in partnership with Show me Your Number will recruit South African sports stars as spokesmen for our workplace and media campaigns.

With EHSA partnership with Project Hope, technical assistance and funds, EHSA will integrate MAP activities in their model farmer and livestock training with men. In addition, they will implement a variety of gender realignment activities and introduce microcredit to some successful clients. EHSA will leverage community and National faith based groups for cordial collaboration to ensure that messages and media campaigns are sensitive to most/all culture and perspectives. Women play a vital role in perpetuating or challenging male gender roles. Gender alignment strategies involve working with women and men separately and then bringing them together for joint discussions. EHSA will work with CEDPA, Marie Stopes, CBO, NGO and district and community clinics.

EHSA will re-launch I AM A PARTNER CAMPAIGN and conduct annual national advocacy and mass media campaigns that tackle negative social norms head on. Each year, EHSA will use multiple reinforcing messages, channels and advocacy tools to address one thematic area in male social norms and HIV. Messages for the general public will be asset-based -

EngenderHealth's Men's Reproductive Health curriculum develops or strengthens health workers' ability to provide quality sexual and reproductive health services (SRH) to men. The course focuses on how to work effectively with men on reproductive health and sexuality issues, including gender concerns and women's RH needs. Modules include: Rationale for providing men's RH services, male sexual and reproductive anatomy and physiology, sexuality, HIV and AIDS, contraception, sexually transmitted infections, and service management, including male friendly services, and counseling and communicating with men and their partners. Because men equate illness or attending health services with weakness, many defer seeking health care until it is too late. When they do seek help, they often feel unwelcome at health facilities, which are largely designed for women. Frequently they confront health workers who are uncomfortable treating them because they have not been trained to do so, are concerned that men's services will be too time consuming, labor intensive, and too expensive to provide, are afraid that men will be threatening or disruptive, or are simply unaware of the factors that attract and repel men.

EHSA and partners will implement a comprehensive supply and demand program at the MAP Centre, including HIV counseling and testing (mobile drives and community testing at the MAP Centre), Couple Counseling, CD4 testing, basic STI and primary health checks services. On the supply side, the project team will work with health workers and sites to address organizational and attitudinal barriers that deter men from using services. Through training, EHSA will build health workers' capacity to attract men to use services themselves and to support their partners' attendance. EHSA will also train health workers on counseling and communicating with men about HIV, both alone and with their partners.

Discrimination against PLHIV is common in South African Health facilities. Fear of discrimination dissuades many men from attending counseling and testing sites to learn their HIV status, and results in PLHIV delaying to seek care and ART. EHSA partners will train government, NGO and private sector health workers to eliminate HIV stigma and discrimination, linking it with universal precautions training to reduce health worker's fears of workplace transmission.

EHSA and Partners will also support sites to introduce locally appropriate male-friendly initiatives, such as displaying HIV BCC materials that appeal to both men and women, scheduling services at times that fit men's work and recreation patterns, providing opportunities for men and women to attend as couples, and involving men in planning, implementing and evaluating services.

MSM and injecting drug users (IDU) have special health and counseling needs. Due to denial of their existence in especially in the rural communities: EC, LP and the severe stigmatization of their behaviors, however, they are unlikely to get the help they need. To increase health workers' awareness, and to help them provide non-discriminatory care, health worker training will include a brief overview of sexual

orientation and the social factors that influence people to start, and to continue using, illicit drugs. Training will include a brief discussion of these men's special health needs plus information on where to refer men for specialized care. As required, EHSA will link with other specialized programs, such as Men's Clinic, to arrange more intensive training for health workers who need it.

Male Circumcision (MC) is now recognized as one of the most promising HIV prevention approaches when integrated with all other HIV prevention, care, and treatment strategies. South African stakeholders believe that community acceptance of MC should not be imposed. EHSA through the MAP Center will work closely with the provincial department of Health and the department of Social Development to determine how to promote male circumcision for HIV prevention in MAP workshops, health worker training, focused group discussions, door-to-doors and community mobilization activities. EHSA will link interested partners with the Male Circumcision Working group in SANAC, to train health workers in clinical MC services including modern surgical technique.

EHSA will work with community groups and outreach workers to increase men's demand for services via existing community mobilization activities and mass media campaigns, and through new specific activities by community outreach workers. In addition, MAP workshop participants will discuss the factors that deter men from using specific services and will examine the importance of seeking help when it is needed. Throughout its work, EHSA will promote messages that equate men's use of HIV services with manhood, strength, and courage. Evidence-based Targeting of Interventions and Selection of Priority Geographic Focus Areas As HIV epidemics mature, the age incidence of new infections rises above 25 years. EHSA will therefore focus on adult but reaching early adult in schools. Targeted evidence-based interventions among higher risk 'bridge populations' are extremely cost effective.

Although EHSA will work with varying intensity throughout South Africa, we will coordinate with government, bilateral and NGO partners to focus activities in 3 provinces (EC, LP and GP) and 3 districts where HIV prevalence is highest, and where risk behaviors and/or gender violence are known to be more common. EHSA will agree on specific sites to set up MAP Centre for comprehensive and integrated activities with collaborating partners. Some activities, such as mass media campaigns and policy advocacy, will be national.

Engaging SA Men SA men are the experts on SA culture and male social norms. EHSA will actively involve men in the communities where MAP Centre will be set up; in the design, implementation, management, monitoring and evaluation of all Project activities. As individuals who are changing their own behavior and providing peer support to their friends who are attempting to do so, as members of Community Action Teams who are raising community awareness, and as activists who are advocating for

legal and policy reform, the men reached by this project will be changed in every sense of the word.

Identifying and Documenting Best Practices In collaboration with the MenEngage Global Alliance and Global MAP, EHSA will support organizations to review existing programs that are working to identify and document success stories and the reasons contributing to their success, and to disseminate the findings widely through MenEngage, professional literature, and local and international meetings.

Capacity Building and Partnerships To ensure sustainability, all EHSA activities will link with and support the NSP Strategy. We will prioritize capacity building of SA public and private sector institutions and community organizations. EHSA will collaborate with and will complement the work of the SA Government. To ensure cost effectiveness, avoid wasteful duplication, and to maximize impact, MAP Centres will add value to existing SA initiatives by strengthening their ability to integrate activities that effectively address prevailing negative male social norms. Programs fall into two categories: a) Those that already reach men and boys effectively but will benefit from "top-up" training, tools and materials to confront issues such as multiple concurrent sexual partners, the role alcohol plays in sexual disinhibition, and attracting men to participate in HIV services. Programs in this category include USG- funded initiatives such as the JHEIPIGO, Futures Group Health Policy Initiative; as well as SABCOHA. b) Those that already reach men and boys but need additional assistance, and/or those working in other development or business fields who do not currently address HIV and male gender norms. These partners will require a greater level of effort in advocating for a focus on male norms and HIV, capacity- building via training and other mechanisms, and tools and materials to incorporate into their programming. Partners in this category include Sonke Gender Justice, Men's Clinic, TAC and DSD.