1. Lecture 4

2. To discuss how social constructions of masculinity prevent many men, women and children from accessing HIV treatment. Think of ways forward

3. 1. Background 2. What is masculinity? 3. Masculinity as a barrier to mens HIV services uptake 4. Masculinity as a barrier to wivess HIV service uptake 5. Facilitators of mens uptake of HIV services 6. Way forward? 7. Group discussions and preparing social action plans

4. ART requires consistent and meticulous monitoring and is most likely to be achieved with the support of a treatment partner, family members and peers from the community (Nachega, Knowlton et al. 2006) ART adherence is optimised in contexts where there can be a certain openness and acceptance of their HIV status (Campbell, Skovdal et al. 2011)

5. Men poor at accessing HIV testing services In South Africa, a survey found that only one in five VCT users were male (Shisana et al. 2002) Men poor at accessing HIV treatment A review of ART access in Africa found that 60% more women enrolled onto ART compared to men (Muula et al. 2007) Men poor at adhering to treatment In Uganda, just over twice as many women managed to keep viral suppression high after six months of treatment (Kipp et al. 2010)

6. Men poor at helping their wives In Zimbabwe, some women on ART felt unable to disclose their HIV status to their husbands, making it difficult for them to adhere to ART (Skovdal, Campbell et al. forthcoming) Men do little to support their HIV positive wives prevent mother-to-child transmission In Tanzania, mens lack of participation in HIV testing and treatment was found to reduce the chances of their HIV positive wives succeed in preventing mother-to-child transmission (Msuya, 2008)

7. 5 min discussion

8. Masculinity refers to a manly character and the way men behave in order to be a real man. Some ways to think about masculinity include Masculinity is a socially and traditionally considered characteristic of being a male A real man is essentially different from a woman A real man is characterized by toughness, competitiveness, strong physique, aggression and unemotionality Many social structures favour men, which means men have more power and control than women

9. Studies have alluded to some of the traits that men in certain cultural contexts are expected to possess. E.g. toughness, unemotional, aggressive, denying weakness, sexually unstoppable, strong and competitive Men are just stronger in terms of resilience… as men, we have been given toughness such that we can pull through even the most difficult situation. James, patient, Zimbabwe Men, as I see them, dont want to know about their status when they are fit and strong, they do not want to appear afraid I think. Not wanting to know what their status is, is like saying Im strong Im strong. Marta, nurse, Zimbabwe

10. 5 min discussion

11. As men try to live up to local understandings and expectations of what it means to be a real man, they may… ignore health messages not be concerned about their health believe they cannot get sick refuse to go to the doctor engage in dangerous activities that put them at risk

12. I think the reason is that men who dont come out, they want to hide and miss out on knowledge. If they hear of a place where AIDS is being discussed, they dont want to go to that place, so men do not have that much knowledge. Spencer, patient, Zimbabwe Men are dying and they dont want to be tested. You hear them saying HIV is like an accident and people cannot stop driving because of accidents, so some men will not change their behavior. Stuart, patient, Zimbabwe

13. ART treatment is complex and require patients to comply with certain instructions. If patients do not comply to the treatment plan laid out to them, this may compromise their adherence to the drugs. Nurses therefore have certain expectations of patients. e.g. Nurses require men to accept their vulnerability and HIV status and to be concerned about their health Even in our cohorts, we have very few men. We can initiate a cohort of 30 patients, you will find only one male and the other 29 will be women. Claudius, nurse, Zimbabwe

14. E.g. Nurses require men to regularly go to the hospital – a place women normally go to Men view health issues as female issues. Women always go to the hospital from pregnancy and until the children are grown up. So men feel hospitals and health concerns are for women. Michael, patient, Zimbabwe E.g. Nurses require men to refrain from unprotected and extra-marital sex and drinking of alcohol. Some men will drink so much that they forget to take their drugs, and even forget that they are patients on ART. Carl, patient, Zimbabwe

15. Patients on ART need to adopt certain behaviours Local expressions of manhood and fear of AIDS are in conflict with what nurses expect from HIV-positive men in need of antiretroviral therapy.

16. The decisions men take to be real men can subordinate the well-being, and indeed even the very survival of the real man himself. This resonates with Clatterbaughs (1997) argument that, as men participate in the construction of powerful masculinities, they often place themselves in a disadvantaged position when it comes to health care access.

17. Mens lack of participation in HIV services, coupled with their sexuality, leaves women susceptible for re- infection. I am very unsatisfied and I feel pulled down when I am dealing with a female patient whose male counterpart refuses to come for HIV test. […] she may be re- infected at home Roselyn, nurse, Zimbabwe Because of mens negative reactions to HIV, many women fear disclosing their status to their husbands. I know a certain lady who attended these HIV/AIDS functions and decided to take up HIV tests and she tested HIV positive, but she was afraid of telling her husband even though she suspected him of being the one who infected her. Constantine, patient, Zimbabwe

18. Out of shame, men may deny their wives from taking ART. Some women say their husbands deny them the right to come to the hospital saying you want to expose me that I am HIV positive, so they even go further by stealing their wives hospital cards. Tsitsi, nurse, Zimbabwe If husbands know that they wives are on ART and suspect they are sick too, they may steal their wifes ART. She may even cry telling you; I have a problem, my husband doesnt want to come to clinic, when I get my monthly supply, he will grab my tablets and take them himself. Weston, nurse, Zimbabwe

19. Through persuasion and need My wife was worried and was always asking about my health. […] I told her I was fine but she insisted that I should go back to the hospital and show them those swellings. She would always push for me to go to hospital everyday until I felt I should just go. Emmanuel, patient, Zimbabwe Gender sensitive HIV management services Now we have these support groups that are well known to be a platform for HIV/AIDS sufferers to give each other support; it was never like that before. Stephen, patient, Zimbabwe

20. Constructing responsible masculinities I have also stopped drinking so that I can concentrate on my treatment […] I take this programme seriously because my family depends on it. Charles, patient, Zimbabwe What makes me look forward to the future is my health which is in a good condition. Also my family. I look forward to building a good future with my family. Nick, patient, Zimbabwe

21. There is a need for male friendly HIV services There is a need to decentralise HIV services, making HIV services more apparent at a community- level and disassociate them from hospitals which may be seen as female spaces.

22. There is a need for men to be in social support groups where they can renegotiate a masculinity that is more aligned to what nurses expect from them. There is a need to uphold confidentiality and respect patients who wish to keep their status secret.

23. The endorsement of community leaders and role models There is a need for a more systematic discussion about masculinity at a community-level, acknowledging both the ways in which masculinities favour men and how masculinities serve as a barrier for mens access to health services, e.g. at: Community meetings In schools In churches

24. What can you, as nurses, do to facilitate some of the processes that may encourage men to make use of HIV services? What activities can you initiate at community level to challenge gender roles? What activities can you initiate at a clinic level to ensure all nurses are sensitive to the special needs to male patients In what ways will you change the way you communicate with male patients?

25. In groups of five, develop an action plan of activities and initiatives you will instigate upon your return to the clinic to ensure men are more accepting of HIV services. Include activities at a: Community-level Health facility level Interpersonal communication level Discuss how feasible it will be to implement any of these activities. What can you, or a group of nurses, do to successfully implement your action plans?

26. Campbell C, Skovdal M, Mugurungi O, Nyamukapa C, Gregson S. We, the AIDS people…: Through what mechanisms have antiretroviral therapy created a context for ARV users to resist stigma and construct positive identities? American Journal of Public Health Campbell C: Migrancy, masculine identities and AIDS: The psychosocial context of HIV transmission on the South African gold mines. Social Science & Medicine 1997, 45:273-281 Clatterbaugh K: Contemporary perspectives on masculinity : men, women and politics in US society. 2nd edn. Boulder ; Oxford: Westview Press; 1997. Fitzgerald et al.: "No one can ask me 'Why do you take that stuff?'": men's experiences of antiretroviral treatment in South Africa. AIDS Care 2010, 22:355 - 360 Izugbara et al.: Male youth and Voluntary Counseling and HIV-Testing: the case of Malawi and Uganda. Sex Education: Sexuality, Society and Learning 2009, 9:243 - 259. Lindegger G, Quayle M: Masculinity and HIV/AIDS. In HIV/AIDS in South Africa 25 years on: psychosocial perspectives. Edited by Rohleder P, Swartz L, Kalichman S, Simbayi L. London: Springer; 2009: 41-54 Muula et al.: Gender distribution of adult patients on highly active antiretrovrial therapy (HAART) in Southern Africa: a systematic review. BMC Publ Health 2007, 7:63 Nachega J, Knowlton A, Deluca A, Schoeman J, Watkinson L, Efron A, et al. Treatment Supporter to Improve Adherence to Antiretroviral Therapy in HIV-Infected South African Adults. Journal of Acquired Immune Deficiency Syndromes. 2006;43(1):127-33 Kipp et al.: Gender differences in antiretroviral treatment outcomes of HIV patients in rural Uganda. AIDS Care 2010, 22:271 - 278. Shisana et al.: South African national HIV prevalence, behavioural risks, and mass media household survey 2002. Cape Town: Human Sciences Research Council; 2002. Images by Peter Strauli