Reaching Men in the HIV Epidemic: Building Inclusive Strategies
- Vusi Kubheka
- Jan 6
- 10 min read
HIV continues to be a global health crisis, yet efforts to tackle the epidemic often leave men behind. Despite national strategies and policies aiming to engage men and boys, structural barriers and narrow interventions hinder their involvement. This poor response to the many interventions aimed at improving HIV testing and antiretroviral therapy (ART) initiation not only affects men but also increases women’s vulnerability to new HIV infections, threatening to reverse the progress made in addressing the epidemic (Hlongwa et al., 2019).
With the health outcomes between men and women widening – studies show that HIV-positive women experience significantly lower mortality rates and enjoy a life expectancy up to 10 years longer than their male counterparts – there must be a greater emphasis on male-centred HIV programmes and services that improve the rate of HIV testing, ART initiation and adherence.
Across sub-Saharan Africa, men are consistently less likely than women to test for HIV, start treatment, or remain adherent to ART programs. This disparity stems from various systematic factors, including the design of health services, which often fail to consider men’s unique needs.
Men’s suboptimal engagement in HIV programmes is reflective of their larger infrequent interactions with the health system compared to women. Women often access healthcare services through family planning, antenatal care, and paediatric services, which provide opportunities for routine opt-out HIV testing and other related services (Mantell et al., 2019). These built-in entry points of contact with the healthcare system are largely absent for men, leaving a significant gap in HIV service provision (Mantell et al., 2019).
Structural obstacles within health system policies further exacerbate this gap. These include exclusionary laws, limited accessibility of affordable services at convenient hours for working individuals, extended waiting times and insensitivity towards the health needs and preferences of adolescent boys and men (Pascoe et al: 2018). Several studies have observed that men’s interactions with public healthcare facilities are often perceived as uncomfortable and ‘female-dominated’ spaces. For example, in Gauteng, South Africa, participants in Leichliter et al.'s (2011) study expressed displeasure with the unwelcoming nature in public clinics due to being overwhelmingly staffed by women and filled with female patients. One participant remarked, “They don’t feel comfortable going because all the docs and nurses are female, and the clinics are full of women.”. This discomfort is compounded by reports of rude and unfriendly treatment from nurses in public clinics, further alienating men.
Similar patterns have been observed in other countries, such as Malawi. Dovel et al., (2020) noted that the organisation of health institutions centred around children’s and women reproductive health in ways that deterred men’s engagement. The national health guidelines offered few recommendations for men of reproductive ages (15-44) to access routine care when compared to women of the same age range (Dovel et al., 2020). Aside from HIV testing, voluntary medical male circumcision (VMMC), and acute care, men have few universal entry points for provider-initiated testing-and-counselling (PITC). PITC, which is a strategy where healthcare providers proactively offer HIV testing and counselling during routine visits, remains underutilised for men. This further perpetuates the community-level perception that health services and facilities are women’s spaces (Dovel et al., 2020).
Dovel et al. (2020) further highlighted that the traits required for patients to successfully access HIV testing services often aligned with characteristics traditionally viewed as 'feminine'. These traits included compliance (obeying provider instructions without a justification as to why instructions were given), deference (being respectful and passive to providers, regardless of provider behaviour); and patience (waiting extended hours), deference (showing respect and passivity toward providers regardless of their behaviour), and patience (enduring long waiting times). Providers may be less inclined to offer services or provide optimal care to men who do not exhibit these traits. For instance, in Zimbabwe, children accompanied by male guardians were less likely to be offered HIV testing compared to those with female guardians. Similarly, in Uganda, men were sometimes excluded from antenatal visits, even when attending as part of a male involvement program.
The Inefficiency of Narrow Gender-Transformative Programs
International policies aimed at engaging men and boys in gender-transformative programs often frame them in instrumental terms, focusing on their roles in facilitating women’s access to health and rights (Pascoe et al., 2018). While this approach underscores the importance of gender equality, it often reduces men to supporting actors in the broader goal of women’s empowerment. This narrow perspective not only limits the scope of these programmes, it also perpetuates a view of men as a homogenous group who uniformly benefiting from privilege. This neglects men who are disempowered by hegemonic masculinity and other intersecting factors such as race and class (Pascoe et al: 2018; Mfecane: 2013). Without acknowledging the vulnerabilities that some men face (such as MSM and gender non-conforming men), these HIV policies and programmes reinforce erroneous and regressive narratives about men’s invincibility (Pascoe et al: 2018).
Though some gender transformative programmes recognise the fluidity and multiple constructs of masculinities, several scholars have highlighted that programmes that engage with men by focusing on changing problematic gender norms, individual beliefs and masculine tropes may constrain the recognition of significant influences in the interpersonal, institutional, and socio-cultural spheres (Dworkin et al, 2015). Emphasising the problematic norms of men’s individual beliefs and behaviours places the burden of intersecting and entrenched aspects of class, race, poverty and economic marginalisation on individual men to overcome (Dworkin et al, 2015). It also suggests that men’s behaviours are exclusively “agentic choices” and does not place this agency within the confines of the socio-cultural, economical and historical influences that facilitate men’s individual and collective choices (Dworkin et al: 2015).
Masculinities are not simply amalgamations of norms and behaviours to negate or solve at the individual and small group levels. They are moulded by structural factors such as racism, poverty, migration and globalisation. Yet only 3 of 15 gender transformation interventions reviewed by Dworkin, Treves-Kagan and Lippman (2013), included efforts of community level changes and mobilisation to address these structural factors. Interventions that directly targeted structural changes were even fewer.
There is a need for more health programmes and policies which address the context in which individual behaviours are enacted. Global health research with women recognises that structural changes are important in improving the range of femininities available to women which in turn results in the improved sexual and reproductive health outcomes for women (Dworkin et al, 2015). However comparable interventions for men remain scarce. Dworkin et al. (2013) found that men involved in gender transformative, anti-violence and HIV programmes were victimised and problematised in narratives of violence. These programmes emphasised men and violence unintentionally and portrayed men as only perpetrators in issues of abuse and violence. Participant feedback from gender transformative research such as “I can say that they are researching men because they say men are lacking somehow in their behaviour” (Dworkin et al, 2015, 7) show the limitations of interventions that focus on problematic gender norms which inscribe men with the individual responsibility of immense social issues while snubbing structural changes that could expand possible masculinities.
A related issue is that gender transformative programmes prioritise gender as the key axis of intervention which importantly overlooks the “intersectional nature of the identities and inequalities that shape men’s health outcomes” (Dworkin et al: 2015, 9). In the context of black South Africans having a 31.1% HIV infection rate compared to a 1.1% HIV infection rate among white South Africans there is a clear need to understand inequality and health outcomes from multiple axis. Discourses of masculinities are more subtle and complex when considering socio-economic and cultural aspects such as entrenched racial, class and gender inequalities. Declining levels of formal employment in South Africa against the empowerment of women has resulted in men perceiving themselves as unable to attain these highly valued features of masculinity (being a provider). This shows us that masculinities are not just confined to gender norms but also the experiences and identities of men that are constructed in the race and class intersections of post-apartheid South Africa.
Differentiated Service Delivery Models: Adapting HIV Care for Men
HIV Differentiated Service Delivery Models (DSDM) adapt HIV-related services to meet the specific needs and preferences of different groups of individuals living with HIV. These models have the potential to address some of the barriers preventing men from engaging with HIV services. Bemelmans et al. (2014) describe four adapted healthcare delivery models developed by Médecins Sans Frontières in Malawi, Mozambique, South Africa, and the Democratic Republic of Congo (DRC) (Bemelmans et al., 2014). These models focused on out-of-clinic and patient-led approaches that reduced the financial and time-related burdens of frequent clinic visits (Bemelmans et al., 2014).
In Mozambique, Community ART Groups (CAGs) exemplify a successful patient-led approach. Stable patients organised themselves into groups of six, with each member taking turns to collect medication for the group every month. This arrangement ensures that every member engages with the clinic at least once every six months, during which they receive medical checks, CD4 count testing, and referrals for additional services (Bemelmans et al., 2014).
In Zimbabwe, similar Community Antiretroviral Refill Groups (CARGs) are another example of community-based, patient-led that have found early success, especially among voluntary participants. These groups provide stable ART patients solidarity, psychosocial support and community-based medication refills. By reducing the need for frequent health facility visits, CARGs have eased logistical challenges for many patients (Mantell et al., 2019).
Significant benefits highlighted from CARGs by participants was the reduced clinic visit frequency and reduced feelings of isolation achieved through the psychosocial support (Mantell et al., 2019). Yet this infrequent contact with health facilities was the same reason for men’s suboptimal engagement with CARGs. Healthcare workers expressed concerns that this made it harder for them to monitor individual patients on a regular basis. Men who were not members of CARGs noted women’s more frequent engagement of health facilities allowed them to access more health information and their work conditions required them to be away from their communities for extended periods to have heard about CARGs. A crucial point in this is that some men thought CARGs was for women. Attempts to recruit men for ART adherence clubs in Khayelitsha, Cape Town, also experienced similar challenges due to men’s employment commitments
Efforts to bridge this proximity should leverage workplaces, entertainment venues, and other male-dominated spaces to raise awareness about the benefits of DSDMs. Flexible service models, including clinic hours outside standard working times, are also crucial for engaging men more effectively (Mantell et al., 2019; Venables et al., 2019). This is particularly important for HIV-positive men, as sustained engagement with health facilities following a positive diagnosis is critical for long-term outcomes.
Addressing Stigma and Gender Norms
A major deterrent to men’s participation in community and patient-led HIV services is the fear of stigma (Mantell et al., 2019). Men often go through extensive measures in fear of confidentiality breaches such as attending public clinics outside of their communities, going to private health facilities or a pharmacy.
The lack of secrecy provided in these models conflicted with dominant gendered norms of masculinity, particularly amongst those who occupied socially valued roles such as husbands, fathers and productive community members. This highlights the communal nature in which such healthcare models and systems must navigate in order to reach more men. Secrecy is often seen as a form of denial that perpetuates HIV-related stigma, but it can also serve as a means of agency, enabling vulnerable individuals to manage who has access to sensitive and potentially harmful information about them (Rhine, 2016). These patient-led models could benefit from encouraging patients to form their own groups and permitting men-only groups as efforts to incorporate their desires for secrecy (Dovel et al., 2020).
Conclusion
While community and patient-led interventions such as CAGs have shown promise in reducing financial and time-related barriers and providing psychosocial support, they fail to address the fundamental issue: The infrequent nature of men’s engagement with the health system. Men’s limited interactions with healthcare services remain a significant obstacle to their sustained participation in HIV-related programs.
These models, while effective in minimizing clinic visits, do not address the deeper structural and cultural factors that deter men from accessing health services. There is an urgent need for interventions that actively work with masculinities instead of circumventing them. This approach requires a deeper understanding of the dynamic and evolving nature of what men and boys consider important to their identities and roles. Recognizing these priorities can help design health services that resonate with men’s lived realities, fostering greater participation and ownership.
For instance, health programs could explore how traditional roles, such as being a provider or protector, intersect with health-seeking behaviours. By framing HIV services as essential to fulfilling these roles – ensuring the ability to support family and community – interventions could align health behaviours with valued aspects of masculinity.
Additionally, participatory research is needed to explore how masculinities influence men’s engagement with healthcare. Programs must consider men’s priorities, challenges, and expectations, crafting messages and services that empower men to see health-seeking as a strength rather than a vulnerability.
References
Bemelmans, M., Baert, S., Goemaere, E., Wilkinson, L., Vandendyck, M., van Cutsem, G., Silva, C., Perry, S., Szumilin, E., Gerstenhaber, R., Kalenga, L., Biot, M., & Ford, N. (2014). Community-supported models of care for people on HIV treatment in sub-Saharan Africa. Tropical medicine & international health : TM & IH, 19(8), 968-977. https://doi.org/10.1111/tmi.12332
Dovel, K., Dworkin, S. L., Cornell, M., Coates, T. J., & Yeatman, S. (2020). Gendered health institutions: examining the organization of health services and men's use of HIV testing in Malawi. Journal of the International AIDS Society, 23 Suppl 2(Suppl 2), e25517. https://doi.org/10.1002/jia2.25517
Hlongwa, M., Mashamba-Thompson, T., Makhunga, S., & Hlongwana, K. (2019). Mapping evidence of intervention strategies to improving men's uptake to HIV testing services in sub-Saharan Africa: A systematic scoping review. BMC infectious diseases, 19(1), 496. https://doi.org/10.1186/s12879-019-4124-y
Leichliter, J. S., Paz-Bailey, G., Friedman, A. L., Habel, M. A., Vezi, A., Sello, M., Farirai, T., & Lewis, D. A. (2011). 'Clinics aren't meant for men': sexual health care access and seeking behaviours among men in Gauteng province, South Africa. SAHARA J : journal of Social Aspects of HIV/AIDS Research Alliance, 8(2), 82-88. https://doi.org/10.1080/17290376.2011.9724989
Mantell, J. E., Masvawure, T. B., Mapingure, M., Apollo, T., Gwanzura, C., Block, L., Bennett, E., Preko, P., Musuka, G., & Rabkin, M. (2019). Engaging men in HIV programmes: a qualitative study of male engagement in community-based antiretroviral refill groups in Zimbabwe. Journal of the International AIDS Society, 22(10), e25403. https://doi.org/10.1002/jia2.25403
Rhine, K. A. (2016). The unseen things: women, secrecy, and HIV in Northern Nigeria. Indiana University Press.
Venables, E., Towriss, C., Rini, Z., Nxiba, X., Cassidy, T., Tutu, S., Grimsrud, A., Myer, L., & Wilkinson, L. (2019). Patient experiences of ART adherence clubs in Khayelitsha and Gugulethu, Cape Town, South Africa: A qualitative study. PloS one, 14(6), e0218340. https://doi.org/10.1371/journal.pone.0218340
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