"As Eastern and Southern African countries heed the call to implement programmes aimed at engaging men and adolescent boys in the HIV response, it is invaluable to be able to refer to strategies and programmes already being implemented within the region and learn from their successes, strengths, and challenges."
This publication highlights six promising practices in the Eastern and Southern Africa (ESA) region that have worked to increase men’s access to and use of HIV prevention and treatment services. It is meant to inform and inspire programmes that aim to engage men in the HIV response, particularly programmes implemented on a nationwide level and is intended primarily for policymakers, planners, and implementers of HIV prevention and treatment programmes across the social and health sectors and including government officials, civil society organisations, and community-based organisations.
As explained in the report, "It is now well understood that gender norms, as they affect both women and men, underpin the HIV epidemic and need to be addressed urgently. Women are much more vulnerable to HIV infection; men are much less likely to get tested for HIV, less likely to access and adhere to treatment, and are thus disproportionately more likely to die of AIDS than their female counterparts. In Eastern and Southern Africa, 58% of new infections were among women; 67% of women living with HIV are on treatment, while only 51% of their male counterparts are on treatment. AIDS-related deaths declined more rapidly between 2010 and 2016 among girls and women (48%), as opposed to AIDS-related deaths among men and boys, which only declined by 29%. As a result, the majority (54%) of all adult AIDS-related deaths were among men.
Engaging men and adolescent boys is a necessary and much-needed component of halting the HIV epidemic because:
- Addressing the norms about masculinity that encourage men to view health-seeking behaviours as a sign of weakness - and the policies and systems that reinforce these norms - will increase men’s uptake of HIV prevention and treatment services;
- It will increase men’s support for gender equality; and
- It will reduce the likelihood that men acquire or transmit HIV.
Engaging men and adolescent boys in HIV and sexual and reproductive health and rights (SRHR), however, requires a gender sensitive and, ideally, gender transformative approach that combines three strategies to increase male engagement:
- Engaging men as clients with their own health needs;
- Engaging men as equal and supportive partners both in and outside of healthcare needs; and
- Engaging men as agents of positive and gender equitable change in their community, country, and region."
The six promising practices include strategies such as Voluntary Medical Male Circumcision (VMMC) and male involvement in prevention of mother-to-child transmission (PMTCT), which are becoming increasingly accepted and scaled up across the region. As stated in the report, “Such strategies are essential to engaging men in the HIV response, but in implementing such strategies it is equally imperative to ensure that such strategies promote, rather than inhibit, gender equality and men taking responsibility for their health.” Other strategies highlighted are those using innovative supply and demand creation approaches such as HIV self-testing and mass media campaigns.
For each programme discussed, the report offers:
- HIV epidemiological data for the country in which the programme is taking place;
- A description of the programme, looking at background, objectives, target population, and key implementation strategies;
- Also includes is a gender analysis of each programme, including the degree to which each programme engages men as: clients, supportive partners, and as agents of change. Integrating all three components of engaging men is critical for long-term positive outcomes for health and gender equality.
- Reasons for success and lessons learned, according to the different levels of engagement: enabling environment; health systems; and service delivery.
The six promising practices are divided into three sections and are as follows:
Section A: Involving men through prevention of mother-to-child transmission of HIV (PMTCT) programmes
Promising Practice 1: Using a family-oriented approach to increase HIV testing among men in Rwanda - This promising practice looks at the “Going for the Gold” campaign, which is built upon high-level policy advocacy as well as local and community-based mobilisation. The objective is to support a family-oriented approach to PMTCT in line with national strategies, with strong emphasis on male participation and encouraging male partners to attend antenatal care (ANC) visits and to get tested for HIV.
Promising Practice 2: Providing a male health service package in Uganda - Based on global and country-specific evidence that demonstrates the positive impact of male involvement on, in particular, the utilisation of services such as ANC, facility-based delivery, HIV testing, and PMTCT, this 2-year multi-faceted initiative was launched in 2013 by the Optimizing HIV Treatment Access for Pregnant and Breastfeeding Women Initiative (OHTA) to increase male involvement in reproductive, maternal, newborn and child health (RMNCH) in three regions in Uganda.
Section B: Involving men through voluntary medical male circumcision (VMMC) initiatives
Promising Practice 3: Using community-based approaches to increase uptake of VMMC in Kenya - This initiate was implemented mainly in regions that had particularly high HIV prevalence and low circumcision rates, including the Nyanza Province, where there was cultural resistance to circumcision among those in the majority ethnic group, the Luo. To address this resistance, community-based efforts were scaled up, including local stakeholder meetings (to ensure that local leaders endorsed VMMC and encouraged their male constituents to seek VMMC) and community dialogues.
Promising Practice 4: Using a traditional “rite of passage” to improve HIV prevention and gender equality among men in Swaziland - This VMMC initiative, called “Lihawu (Shield) Male Mentoring Camp”, encourages a Bantu initiation “rite of passage” approach to VMMC in combination with a multi-day, male-only camp engaging young men around positive masculinity and responsible adulthood.
Section C: Involving men through innovative supply and demand creation approaches
Promising Practice 5: Increasing access to HIV self-testing in Kenya - The promising practice highlighted here is of a pilot study implemented across several sites in the city of Kisumu that explored secondary distribution of HIV self-test kits by women to their sexual partners. Secondary distribution is a strategy in which easier-to-reach individuals - in this case, women accessing health services - are given multiple self-tests to distribute to harder-to-reach individuals, such as male sexual partners or clients. In particular, this study recruited HIV-negative women aged 18-39 accessing antenatal or postpartum care and female workers accessing HIV prevention and care services at a drop-in clinic.
Promising Practice 6: Using mass media and community mobilisation to transform gender norms in South Africa - Brothers for Life, or B4L, is a multi-faceted national mass media and community mobilisation communication campaign launched in South Africa in 2009. Intended to be more of a catalyst for a social movement than a standalone campaign, B4L addresses the range of risk factors driving the spread of HIV and seeks to influence social norms that define masculinity and influence gender relations and to positively impact specific areas of knowledge and practice in HIV prevention.
For the first two sections, the report also highlights what works and common challenges or weaknesses related to that approach. For example, for involving men through PMTCT programmes, under what works, the report cites the use of male role models (“male champions”) and existing community health worker networks. In addition, shifting the burden of requesting male partner engagement from pregnant partner to the health system (such as through letters), but only with consent from pregnant partner, is a good strategy. A challenge cited is the insufficient gender sensitisation of health providers to ensure that services are welcoming to male clientele and that their staff are competent to meet their needs. Factors that work for involving men through VMMC initiatives include: well-trained and sensitised health providers providing non-judgmental and male-friendly services, as well as clear and concise messaging around procedure, disposal of foreskin, and post-circumcision healing, and appearance for both target audience and broader community. A challenge cited is the lack of strong engagement with women as partners and agents of change.
Sonke Gender Justice Network website on January 30 2018.