Engaging Men in Prevention and Care for HIV/AIDS in Africa

Published: February 7, 2012

Targeting men in prevention and treatment, however, may have a large impact on mortality, new infections, and the economic impact of HIV/AIDS in Africa. In the wake of the HPTN 052 trial results, demonstrating 96% (95% confidence interval, 73%–99%) efficacy of prevention in discordant couples with earlier ART treatment initiation, engaging greater numbers of men with HIV in treatment could have important prevention benefits for women and girls, and for primary prevention of vertical transmission [1].

Neglect of Men in HIV Prevention and Treatment Campaigns Top
In the last half-decade, there has been discussion over the need to actively engage men in sub-Saharan Africa in HIV prevention campaigns. Several randomized trials in South Africa have examined interventions aimed at male behavior change [8]–[12]. Further work has come from the social science disciplines, where researchers and gender advocates have created gender-focused HIV prevention frameworks and contextualized the role of men in contributing to the epidemic [5],[13],[14]. Although much of this work has examined attitudes and behaviors, there is emerging recognition from a number of epidemiological sources that men in sub-Saharan Africa face important challenges in terms of HIV vulnerability, engagement and retention in care, and access to ART that affect mortality [15],[16]. Taken together, the evidence indicates that men are under-represented in HIV testing, treatment, and care, and this likely has a direct impact on outcomes of care [17]–[21].

While public health efforts have been aimed at women, particularly child-bearing women (e.g., HIV testing, care, and treatment opportunities provided through antenatal care services), scale-up efforts are hindered by the differences in health-seeking behaviors between men and women [22]. For instance, sickness may be seen as a sign of weakness for many men, and this perception has resulted in a reluctance of care-seeking among men [23]. There is also evidence indicating that men may feel that they have been caught at their hidden sexual behaviors and so they avoid HIV testing [23]. Additionally, employment-related migration will keep men away from their partner and families for long time periods, and this absence may make them more vulnerable to HIV infection due to sexual exposure, drug and alcohol use, and delinkages with local health services [22]. The reality that men are less likely to seek health care is intimately linked to perceptions of masculinity, and is generally considered to be part of the same phenomenon that drives multiple partnering, violence against women, substance use, and homophobia among men [5],[13].

There is now also a growing appreciation that the HIV/AIDS epidemic in Africa is driven by complex and poorly understood sexual dynamics that include, among others, concurrent partner relationships and multiple partner relationships involving both males and females [24]–[26]. The available evidence indicates that infection is equally balanced between males and females in most heterosexual settings [25].

Failing to engage men in HIV prevention and treatment may also have an impact on household family income. In Africa, men are typically the larger income-generators, often engaged in employment outside of the home, whereas women are more likely to be engaged in economic activities closer to home as well as child caring. If the head male member contracts HIV and does not receive the appropriate care, ill health or death of this individual can severely impact household family income.

While our discussion here is predominantly focused on heterosexual men, we cannot ignore that men who have sex with other men (MSM) are one of the most difficult groups to target in prevention and treatment campaigns in Africa. Data on the magnitude of MSM or the prevalence of HIV in this population are sparse [27]. The recent crackdown on MSM in Uganda, where the government petitioned a law before parliament to make MSM sexual activities illegal, potentially punishable by death for those who are HIV positive, demonstrates that certain male groups require specific care and support [28]. The law, largely condemned around the world, also placed pressure on HIV/AIDS service providers, as anyone, including organizations, aware of homosexual activity and failing to report the act could be punished with up to three years of imprisonment. With the popular support the bill has received, HIV/AIDS service organizations have been challenged to provide strong advice to their employees on how to treat MSM patients. Similar legal and cultural oppression of MSM occurs in other African countries.

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