In South Africa, men experience worse HIV-related outcomes than women. It is estimated that 78% of men living with HIV know that they are HIV-positive, versus 89% of women – 67% of men who have been confirmed as HIV-positive are on treatment, compared with 72% of women. Research is needed to understand the dynamics of this disparity and to design interventions to close the gap.
This qualitative study reported in the SA Health Review aimed to describe both men’s experience accessing HIV services and the experience of healthcare providers delivering such services in order to understand why men at risk often do not test for HIV or initiate treatment after testing positive. Fifty-eight black South African men were interviewed: the respondents were from KwaZulu-Natal and Mpumalanga, aged 25 – 34 years, sexually active, and had not undergone voluntary medical male circumcision.
Sixty-four healthcare providers working in public or non-governmental organisation clinics in the same provinces were also interviewed; each interviewer had at least five years’ experience testing and treating men. The interviews were analysed thematically. Many men live in an environment of uncertainty and perceive testing and treatment as burdensome. While social norms prime them to appear indifferent, many are afraid.
They believe that a positive diagnosis will bring loss of status and relationships, so many prefer not to test, or they delay treatment. This is compounded by traumatic childhood memories of the early days of the Aids epidemic. At clinics, some men perceive care to be judgemental, which discourages them from testing. Providers express frustration with men’s apparent apathy, although this is often a misreading of men’s fear. Health worker frustration is compounded by the challenges of the healthcare system, including pressure to reach ambitious targets and to comply with administrative requirements.
Although the study was geographically limited and the sample was not designed to be representative, the results suggest that current approaches may be inadvertently driving men away from services. Clinic reorganisation, provider training, and greater understanding of the needs of men and healthcare providers may increase men’s uptake of HIV services.
The research found that a large body of literature describes vulnerability to HIV acquisition among adolescent girls and young women. Comparatively less is known about men, even though men are less likely to test for HIV, less likely to initiate treatment if positive, and less likely to adhere to treatment once started, all of which results in significantly lower rates of viral suppression.
Gender disparities are reflected in mortality data: women are 27% less likely to die from HIV than men, and more than half of all male HIV-related deaths occur in men who have never sought HIV and Aids care. The literature shows that men’s vulnerability to HIV can be partially attributed to masculine gender norms.
An extensive body of work reveals the role of masculine constructs in fuelling HIV acquisition – the value placed on strength, self-sufficiency and overt expression of sexuality. Myths of male invulnerability and shame in seeking help; pervasiveness of excessive alcohol consumption; social marginalisation of certain groups of men, which along with unemployment, “creates a nexus of trauma, poverty, and depression”; anticipated stigma; and exclusionary language and policies in health clinics act together to inhibit men’s HIV testing and care-seeking.
This is especially problematic for black men in South Africa, who experience higher HIV prevalence than other racial groups. This has been attributed to differences in sexual behaviour, but should also be considered in the context of socio-political factors including colonialism, apartheid and forced migration, which have facilitated the spread of HIV among this group.
[link url="https://www.hst.org.za/publications/South%20African%20Health%20Reviews/11%20SAHR_2019_Understanding%20barriers%20to%20HIV%20testing%20and%20treatment.pdf"]SA Health Review research[/link]