Before I departed for South Africa in 2018, our team had been told that men there would never take a daily pill for HIV prevention.
According to the Center for Strategic & International Studies, South Africa remains the epicenter of the HIV pandemic — 20 percent of all people living with HIV are in the country and 20 percent of new HIV infections occur here as well. I was traveling to South Africa with Maverick Collective, a community of women philanthropists brought together to make catalytic investments in global health initiatives that are conceived locally and scaled through the international NGO, PSI. Our intention on this trip was to connect with South Africans in and around the Gauteng province to learn how we might support the community’s efforts to address the HIV epidemic.
PrEP, a pre-exposure prophylactic shown to reduce the risk of HIV transmission by up to 74 percent, was already available in many countries around the globe at low cost but wasn’t being used at scale in South Africa. There wasn’t much research to shed light on why this was the case. Most government initiatives were focused on treatment for HIV rather than prevention, due in some part to having to work with limited resources. I worked with PSI to determine how we could use private capital to try and approach the problem differently. The team hypothesized that there was an opportunity to focus on getting PrEP to men, and that centering men in the design of PrEP delivery programs would be the most effective approach to the HIV epidemic in South Africa.
Up to this point, general societal assumptions suggested men were irresponsible, and it was widely believed that men never do and never would partake in health-seeking behaviors. After several months of ethnographic, qualitative, and quantitative research in collaboration with the global research firm Ipsos and the local design firm Matchboxology, we found indications that men were motivated to take precautions around HIV and take care of their own health. We talked with 2095 men to better understand their barriers to accessing HIV services. Turns out, many men we talked to had never been asked what would work for them.
Not only were men not consulted on what prevention efforts might best fit their lifestyles, we found that very few South African men were even aware that PrEP existed. For those who had heard of the drug, there was widespread confusion around the differences between PrEP, a pre-exposure prophylaxis, PEP, a post-exposure prophylaxis, and ARTs, antiretroviral therapy for treatment of people already infected with HIV. Additionally, a lack of training on men and PrEP led to further confusion and fear. For example, many health care workers believed if an individual didn’t take their pills at the exact perfect time every day, PrEP wouldn’t work. In reality, so long as PrEP is taken daily regardless of time of day, it will remain effective. Additionally, men told us they felt the general messaging around their health care practices was infantilizing and fatalistic. That could certainly dissuade adoption of a new behavior.
The good news? With an investment in awareness, access, and guidance on flexible use, along with the expansion of PrEP outreach services, it seemed that a large uptick in the use of PrEP in men in South Africa was possible, resulting in a decrease in HIV infection rates. The men we spoke to were not only decidedly open to the idea of taking a daily pill to reduce their risk of contracting the disease, many were willing to spread the word and encourage friends to get on PrEP too.
Dispelling societal perceptions of men in South Africa as careless about health while addressing knowledge gaps opened the door for PrEP to be successfully distributed to men who could benefit from it. By 2021, drawing on these research insights, PSI was able to run a PrEP pilot with 564 men and analyzed data from another PrEP program with 1971 men. After one month, without further intervention, over half of the men returned for a follow-up evaluation — an incredibly promising outcome.
We were able to uncover and support this new way forward because we had flexible funding to focus on truly understanding the community and the root barriers to adoption before attempting to implement a potentially ill-fitting solution. This is the philanthropic funding model we need to effectively fight the HIV epidemic, and it’s beneficial for all sorts of social challenges. It is essential to work on the ground with local people who are the experts in their own culture and context and enroll them in the design of solutions that put autonomy and care in the hands of the community.
We must be willing to begin solution-agnostic and fund locally designed ideas. Funding without a projected outcome may be an unconventional approach to philanthropy, but the conventional isn’t always the most impactful. As a funder, I choose to support boldness, back community-centered initiatives, and trust the use of flexible funding. I believe it’s critical to go where conventional funders won’t and use private capital to look at problems differently than traditional approaches typically allow. For philanthropy to drive innovation it must be willing to try a new way. It’s time to go that new way and shift the power of decision-making and design from donors to proximate leaders in communities.
Anu Khosla is a freelance brand strategist, philanthropist, and a member of Maverick Collective by PSI.