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Briefing Document 33

HIV and Men

This Briefing Document explores issues surrounding HIV/AIDS and Men, including special circumstances which place men at risk, prevention, strategies for working with men and biological factors which place men at risk.

Briefing Document #33 is one of an on-going series. Visit the catalogue of Briefing Documents.

The Briefing Documents are created by
AIDS Calgary Awareness Association

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HIV and Men

Gender - the different roles that men and women play in a society and the rights and responsibilities associated with those roles - is a powerful force. Gender roles and gender norms are culturally specific and thus vary tremendously around the world.2 Almost everywhere, however, men and women differ substantially from each other in power, status and freedom. In virtually all societies, men have more power than women.2 Although their position of power in the world confers many benefits to men, it can also endanger their health.1

 

The myth of masculinity leads to expectations of men to be physically strong, emotionally robust, daring and virile.2 Some of these expectations translate into attitudes and behaviours that have become unhelpful or frankly lethal with the advent of AIDS.1 Others, on the contrary, represent valuable potential that can be tapped by HIV/AIDS programs.1

Why Should Men Become More Fully Involved in the Fight Against HIV/AIDS?

A number of special circumstances place men at particularly high risk of contracting HIV:

  • Worldwide, men tend to have more sex partners than women, including extramarital partners, thereby increasing their own and their partners risk of HIV 1. Studies confirm that boys and men across the world report sex with other boys and men.3 Some men may have discreet relationships with other men so long as they also marry and have children.3 This places both the man’s male and female partners at risk. Secrecy and stigma stifle discussion about HIV between couples.

  • Men are often less likely than women to seek health care 2 - this may be associated with delays in treatment of STD’s and other health concerns. Untreated STD’s have been associated with a five-fold increase in risk of HIV transmission. 1

  • Men who migrate for work and live away from their families may pay for sex and use substances including alcohol, as a way to cope with the stress and loneliness of living far from home. 1 This can further contribute to the spread of HIV, when these men return to their communities and their primary partners.

  • Men in all-male environments, such as the military, may be strongly influenced by a culture that reinforces risk taking.1 The UN Security Council has recently approved a program which will attempt to prevent and treat HIV/AIDS within the UN peacekeeping forces. The UN has acknowledged that UN peacekeepers may contribute to the spread of HIV. The program will involve extensive education for troops before deployment, access to confidential testing and treatment and each soldier will be issued one condom per day.

  • In some institutions such as prisons, men who normally prefer women as sex partners may have sex with other men.4 Men are imprisoned at a much higher rate than women.1 Sex may take place between prisoners, often without condoms. Many prisoners continue to inject drugs while they are in prison. As a result of both sexual and drug-related transmission, there are increased rates of HIV among prisoners.1 In Canada, it is estimated that rates of HIV infection in prisons are ten times the infection rates in the general population.5

  • Men make up 80% of the estimated 7 million injection drug users in the world.1 Studies indicate that although many drug users take HIV preventive measures while using drugs, they fail to do so while having sex.1 For many individuals, the links between IDU and the sexual spread of HIV is not clear.

  • Male violence further drives the spread of HIV though wars and the migration they cause, as well as through forced sex.1 Millions of men a year are sexually violent towards women and girls, sometimes with their own families.

  • Male sex work is common in many countries although it is often hidden and denied since most male, sex trade workers have sex with other men.2 The stigma associated with this area of work makes it difficult to reach men and their customers. Specialized outreach programs are important ways to reach this population.

Men and Prevention

The HIV/AIDS epidemic has put men’s sexual behaviour in the spotlight. Prevention is the only solution.

Most approaches to prevention have looked at the link between knowledge of risk and behaviour change. Most countries have managed to increase knowledge and awareness of HIV via prevention and awareness campaigns. The major stumbling block has been the failure to achieve behaviour change.

Research has shown that there are a number of barriers to the adoption of risk-reduction strategies.3 Many of these barriers arise from and are reinforced by gender roles and socioeconomic inequalities.3

One of these barriers to behaviour change is the concept of masculinity and machismo.4 This refers to the ideas of what it means to be a man. Male sexuality is often portrayed as unrestrained and unrestrainable.4

This conception of male sexuality may be damaging to men. Efforts to increase consistent condom use may be hampered by stereotypes about male sexual response. In one study, men in South America expressed that they knew and believed that condom use was important but were hesitant to refuse sex without a condom, as this might mean they were unmanly.6

Many cultures consider the initiation of sex to be the man’s responsibility. These gender-role expectations constrain sexual negotiations.6 While lack of knowledge and sexual inexperience remain highly valued for young women, men may be stigmatised if they cannot demonstrate having had a wide sexual experience, 6

Acceptance of societal norms about "regular" or steady partners may also impede the use of condoms.3 Notions surrounding trust and romance make it difficult to introduce a discussion of condom use without bringing up issues of infidelity and mistrust.

Another barrier is assumptions about women’s sexual history. Men professed to make judgements about the "cleanliness" of women.3 Women who wore too much make-up and "failed" to resist their advances were considered suspect and so condoms were often used. On the other hand, women who dressed sedately and refused sex on an initial encounter were deemed safe and condoms were not often used. This is consistent with findings that condoms were often used with commercial sex workers but rarely with regular partners.6

Other barriers to condom use include beliefs that condoms compromise the pleasures of sex, are unnatural, are unromantic and spoil spontaneity.6 Embarrassment about purchasing condoms has been found to be an issue for young people and individuals in cultures where sexual discussions are taboo.6

Working with Men

Men are a diverse group of individuals. They reflect the spectrum of humanity, from kind and caring to abusive and dangerous. While some men spread STD’s to their partners or act in other harmful ways, most men do not. It is important that health programs abandon stereotypes of men and learn more about their concerns and needs, especially when designing programs for different groups of men.6

A number of researchers and community groups have recognised the importance of involving men in programs designed to prevent HIV infection, as well as to address the broader inequalities which pose a risk to sexual health. One of the most important gaps in research is the absence of clear information about men’s attitudes towards sex and sexuality.1 We need to know more about men’s perspectives and interests if we are to engage them productively.

Women have reported that men are reluctant to use condoms but little is known about men’s reasons. For example , women in South Africa reported that men could become violent or coercive if condom use was requested. A pilot project asked men about their reaction to requests for condom use. Their responses indicated that they were not against condom use, but they mentioned the importance of timing the request. They unanimously agreed that if the request to use a condom was made before arousal occurred, they were much more likely to respond favourably. This is important information, which can benefit both men and women. 1

Strategies to Increase Men’s Participation

Reach out to young and unmarried men

Worldwide, one in four people with HIV is a young man under age 25.1 Men are more likely to maintain safer sex behaviours if they initiate them at an early age.6 To meet the needs of young men, programs must learn about men’s perceptions of their roles and responsibilities as sex partners.

Programs must also assess what young men actually know about sexual health and start at their level. Many programs start with the assumption that young men understand the basics around sexual intercourse but this may not be the case.6 Machismo may make it difficult for young men to acknowledge that they are actually lacking information about sexual health. Another strategy which has been suggested is the training of young men to work as peer health educators.6

Bring information to where men gather

Allowing men to talk about their problems in a safe environment is an important first step to reaching men with safer sex messages.3 To this end, some clinics have started offering men-only nights, while other clinics are offering services in conjunction with sports events, military facilities and juvenile justice centres.1

In southern India, a program trained more than 250,000 barbers as community health workers. They talk about condoms and distribute them to clients in their shops. Village men say they feel more comfortable talking with their barbers than to clinic workers.6

The cross border mobility of truck drivers, migrant workers and military personnel means that they sometimes play an important role in introducing HIV into an area. Several programs have successfully targeted this group of men.6

Biological Factors

It is estimated that between 75-85 % of HIV cases worldwide have been contracted via sexual contact.7 Globally, most cases of HIV have been spread via heterosexual contact. For most men, this means that HIV has been contracted via the penis.7

Circumcision

There is a growing body of epidemiological evidence which shows that uncircumcised men are at a much greater risk of becoming infected with HIV than circumcised men.7 Currently, it is estimated that uncircumcised men have between 2 to 8 times the risk of HIV infection compared to circumcised men.7

Why are uncircumcised men at risk?

The inner surface of the foreskin contains Langerhans’ cells with HIV receptors. These cells are likely to be the primary point of viral entry into the penis of an uncircumcised man.

Uncircumcised men are susceptible to STD’s via the following mechanism: The frenulum, the thin band connecting the inner foreskin to the glans is made up of highly vascularized (containing many blood vessels) tissue. This makes the frenulum highly susceptible to trauma during intercourse and lesions produced by other sexually transmitted disease commonly occur there.7

This fragile area contains Langerhans’ cells which have HIV receptors. This area is likely to be the reason that uncircumcised men are at greater risk of HIV and other STDs.7

Circumcision has also been shown to protect against other sexually transmitted infections. The presence of another STD can increase the risk of HIV transmission by up to 5 times.7

Although condoms must remain the first choice for preventing the transmission of sexually transmitted infections including HIV, they are often not used correctly or consistently and there may be strong cultural objections to using them. Cultural and religious attitudes towards male circumcision are even more deeply held but in light of the evidence that circumcision offers some protection against HIV, circumcising males seems highly desirable, especially in countries with high levels of HIV infection.

Neonatal circumcision is easy to perform and has low rates of complications.7 One drawback is that it would take 15-20 years before a circumcision program has an effect on the transmission of HIV.7 Another alternative is the use of circumcision at puberty, as practised by many Muslim countries.7 This would be the most immediately effective intervention for reducing HIV transmission since it would be done before young men are likely to become sexually active.

 

References

1. UNAIDS (2000). Men and AIDS - a gendered approach. 2000 World AIDS Campaign.
http://www.unaids.org

2. Greig, A., Kimmel, M. & Lang, J. (2000). Men, Masculinities & Development: Broadening our work towards gender equality. Gender in Development Monograph Series #10. UNDP.

3. Rivers, K, Aggleton, P. (1999). Men and the HIV Epidemic.
http://www.undp.org/hiv/publications/gender/mene.htm

4. Kippax, S. Crawford, J. & Waldby, C. (1994). Heterosexuality, masculinity and HIV. AIDS. vol. 8 (supplement 1), p.5315-5323.

5. HIV/AIDS EpiUpdates. (2000) Division of HIV/AIDS Surveillance, Bureau of HIV/AIDS, STD and TB. Laboratory Centre for Disease Control.
Available at http://www.hc-sc.gc.ca/hpb/lcdc/bah

6. Population Information Program. (1998). Reproductive Health: New Perspectives on Men’s Participation. Population Reports. Series J, number 46.

7. Szabo, R. & Short, R. (2000). How does male circumcision protect against HIV infection?. BMJ. vol. 320, p.1592-1594.

 

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