Addressing a Blind Spot in the Response to HIV
"[S]ocietal gender inequality and many efforts to address it share a common blind spot: how gender norms that encourage male dominance and emphasize myths of male invulnerability are also harmful to men and boys."
Released on World AIDS Day 2017, this report from the Joint United Nations Programme on HIV/AIDS (UNAIDS) shows that men are less likely to take an HIV test, less likely to access antiretroviral therapy, and more likely to die of AIDS-related illnesses than women. Among the data shared: Globally, less than half of men living with HIV are on treatment, compared to 60% of women. Studies show that men are more likely than women to start treatment late, to interrupt treatment, and to be lost to treatment follow-up. The report explores reasons behind these disparities, making recommendations for reaching significantly more men and adolescent boys with HIV prevention, testing, and treatment services.
UNAIDS explains that male gender norms tend to assign roles of power and authority to men and to assert notions that men are more resilient and independent, less vulnerable, and physically more robust than women. These dominant conceptions of masculinity also typically equate risk-taking, aggression, and stoicism with so-called manliness, and they stigmatise illness as a sign of weakness. For many men, seeking help from a health professional conflicts with socialisation that has taught them to prize self-reliance, physical fortitude, and emotional reticence. These gender norms also place high value on sexual conquest and the control of women; studies show that when men equate manhood with dominance over women, having multiple sex partners, refusal to use condoms, and alcohol and substance abuse, they put themselves and their partners at heightened risk for HIV infection. Furthermore, the link between alcohol use by men, increased sexual risk behaviour, and the acquisition of HIV has been documented in a range of subpopulations and settings.
In light of those norms, the report shows the need to invest in boys and girls at an early age, ensuring that they have access to age-appropriate comprehensive sexuality education that addresses gender equality and is based on human rights, creating healthy relationships, and promoting heath-seeking behaviour for both girls and boys.
The report urges HIV programmes to boost men's use of health services and to make services more easily available to men. This includes making tailored health services available, including extending operating hours, using pharmacies to deliver health services to men, reaching men in their places of work and leisure, including pubs and sports clubs, and using new information and communication technologies (ICTs), such as mobile phone apps.
For example, creative marketing and trendsetting can counter the negative preconceptions and questions that persist about condoms. Such efforts would do well to reach men where they socialise. Campaigns on condom use that focus on football fans, for example, have been staged in many countries. There also is potential for scaling up interventions in bars and other drinking venues where customers may be especially likely to meet non-regular sexual partners. For instance, a project in South Africa that recruited male drinkers to special workshops reported an increase in men's awareness of safer sex behaviours and increased condom use.
Reviews of demand generation efforts in sub-Saharan Africa have found that effective strategies for increasing the uptake of voluntary medical male circumcision include communication-related elements such as: using peer influence, including through sports-based programmes, tailoring messages that focus on benefits besides HIV prevention (e.g., hygiene and sexual pleasure), engaging traditional and religious leaders, and deploying community mobilizers to address individual concerns. Imaginative social marketing can be used to increase social acceptance and demand for the procedure. In Zambia, market research was used to generate demand creation tools segmented for men with different knowledge and attitudes, which allowed community health-care workers to tailor their messaging to potential clients. Health-care workers who piloted the new tools booked 26% more circumcision appointments, which in turn led to a 39% increase in actual circumcisions compared to the standard level of care.
In South Africa, behavioural science and mobile technology have been employed to increase uptake of voluntary medical male circumcision. In 3 provinces where 97% of households have access to mobile phones, booking a circumcision appointment was made easier through a toll-free number, and SMS (short messaging service) text messages were sent for booking confirmations and reminders the day before the appointment. Over a two-month period, more than 48 000 people accessed the toll-free number, and more than 11,000 men (24%) were circumcised. The number of circumcisions performed in the pilot areas in November 2016 was 30% higher than it was in the previous year.
A relatively intensive method that has successfully increased uptake in South Africa used trained male circumcision advisers to perform motivational interviews and financial compensation for those who undergo the procedure. Seventy per cent of male participants agreed to be circumcised, with the highest uptake among men in their 40s. Most of the men who opted for the procedure said they had taken the decision after discussing the matter with partners, friends, or relatives.
Adolescent-focused services seem to be most effective when they engage parents and the wider community, occur in an adolescent-friendly environment, and provide counselling in a manner that is easy to grasp. In Swaziland, a 3-day male mentoring camp is designed to allay fear and suspicion about male circumcision among young men (15-29 years) and to provide a comprehensive package of health services. The residential camp combines edutainment games and cultural practices, sensitisation on masculinity and gender awareness, and information on HIV and male health issues and services. At the end of the camp, participants are offered voluntary medical male circumcision and testing and counselling for HIV and other sexually transmitted infections (STIs). Uptakes of voluntary medical male circumcision and HIV testing were 86% and 87%, respectively, compared to a national average of 19%.
Many of the strategies for reaching more men and boys in the general population with HIV services also apply to men and boys within key populations. Argentina has established a policy on key population-friendly health services in order to reduce stigma and discrimination towards gay men and other men who have sex with men, transgender people, and sex workers, and to increase their access to (and uptake of) HIV-related and other health services. Civil society organisations and networks are involved in outreach activities and the design and implementation of services. Twenty-one key population-friendly health centres have been established within the public health system, with interdisciplinary teams of health and social workers providing a variety of health and social services (and in some cases, legal or referral services) that are tailored to the needs of lesbian, gay, bisexual, and transgender (LGBT) populations and sex workers.
In concluding, UNAIDS suggests that progress is needed along two intertwined paths:
- Reach more men with health and HIV services in the short term, and enable them to use and adhere to those services.
- Introduce purposeful policies and practices that remove gender inequalities and promote more equitable gender norms and institutional arrangements to the benefit of both women and men.
To that end, the following transformative actions are recommended:
- Ensure that supportive legal and policy frameworks underpin systematic change. "Reforming or removing discriminatory and punitive laws and implementing protective legal norms empowers individuals and communities, providing an environment where people feel they can access health services safely, with dignity and on an equal basis with others."
- Invest in long-term gender-transformative programmes, particularly those that engage men and boys, to alter harmful gender norms, reduce gender-based violence, and promote gender equality.
- Adopt a firm public health approach to health and HIV service access among key populations, including comprehensive harm reduction approaches, and remove policies and laws that criminalise key populations or sanction their harassment and discrimination.
Systems for health
- Improve understanding of the disparities in health behaviours of men and women, including through standard sex disaggregation of HIV and other health data.
- Revise health and HIV strategies and policies to address gaps and disparities in access to and use of services, whether for men and boys or women and girls.
- Adapt health systems so they reach deeper into communities and meet the diverse health needs of men and women. Make health insurance more accessible and affordable and reduce point-of-care expenses.
- Sensitise and train health-care workers to improve their competence in dealing with the diverse health issues and behaviours of men and boys.
- Make health and HIV services more easily accessible and appealing for men and boys. Clinic procedures and environments should be more responsive to men's health-related concerns, including the desire for confidentiality.
- Make HIV services available outside of traditional clinical settings, including within the workplace and at places of leisure (including sports activities). Time the provision of mobile and other community-based services outside of standard working hours.
- Use community-based HIV testing and counselling (including mobile and home-based testing), community outreach, and self-testing more extensively, and integrate testing into multidisease campaigns and events.
- Ensure HIV testing is confidential to achieve earlier diagnosis of HIV infection in men, and use test-and-treat strategies so that men initiate treatment as soon as possible after diagnosis.
- Strengthen treatment adherence by decentralising services, including drug dispensing, minimising the travel and wait times of clinic visits, and emphasising the benefits of treatment for partners and families.
- Reach men through their sexual partners and spouses and engage them more systematically in maternal and child health services and sexual and reproductive health services, including through strategies such as couples HIV testing and partner-assisted notification.
- Counter perceptions of sexual health as a woman's issue and responsibility. Enlist community leaders and other figures of respect to dispel misconceptions and promote gender-equitable behaviours. Peer influence is a powerful factor in encouraging men and boys to alter their behaviours.
- Use creative marketing and trendsetting to promote the use of condoms and lubricants, voluntary medical male circumcision and other proven HIV prevention measures. These efforts must be socially marketed so they speak to the diversity of men's perceptions, desires, needs and concerns.
- Use social media nudges and reminders, including via mobile phone apps and SMS messages, to discretely provide health information and linkage to services, and to support adherence to prevention, treatment, and care.