Men, masculinity, and engagement with treatment as prevention in KwaZulu-Natal, South Africa

ABSTRACT

Men’s poorer engagement with healthcare generally and HIV care specifically, compared to women, is well-described. Within the HIV public health domain, interest is growing in universal test and treat (UTT) strategies. UTT strategies refer to the expansion of antiretroviral therapy (ART) in order to reduce onward transmission and incidence of HIV in a population, through a “treatment as prevention” (TasP). This paper focuses on how masculinity influences engagement with HIV care in the context of an on-going TasP trial. Data were collected in January–November 2013 using 20 in-depth interviews, 10 of them repeated thrice, and 4 focus group discussions, each repeated four times. Analysis combined inductive and deductive approaches for coding and the review and consolidation of emerging themes. The accounts detailed men’s unwillingness to engage with HIV testing and care, seemingly tied to their pursuit of valued masculinity constructs such as having strength and control, being sexually competent, and earning income. Articulated through fears regarding getting an HIV-positive diagnosis, observations that men preferred traditional medicine and that primary health centres were not welcoming to men, descriptions that men used lay measures to ascertain HIV status, and insinuations by men that they were removed from HIV risk, the indisposition to HIV care contrasted markedly with an apparent readiness to test among women. Gendered tensions thus emerged which were amplified in the context where valued masculinity representations were constantly threatened. Amid the tensions, men struggled with disclosing their HIV status, and used various strategies to avoid or postpone disclosing, or disclose indirectly, while women’s ability to access care readily, use condoms, or communicate about HIV appeared similarly curtailed. UTT and TasP promotion should heed and incorporate into policy and health service delivery models the intrapersonal tensions, and the conflict, and poor and indirect communication at the micro-relational levels of couples and families.

KEYWORDS:

• Masculinity
• HIV
• treatment as prevention
• qualitative
• South Africa

Acknowledgements

The authors wish to thank the Department of Health of South Africa for their support of this study, the community of Hlabisa sub-district for hosting our research, and all participants who contributed to the study.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The French National Agency for Aids and Viral Hepatitis Research (ANRS) is the sponsor of the TasP trial. The ANRS and the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) provided funding for the first phase of the trial [under the grants Agence Nationale de Recherches sur le Sida et les Hepatites Virales (ANRS) 12249 and GIZ N°81151938]. The on-going second phase of the trial is now co-funded by the ANRS, and the Bill and Melinda Gates Foundation through the 3ie Initiative. The trial is conducted with the support of Merck & Co. Inc and Gilead Sciences that provided the Atripla® drug supply. The Africa Centre for Population Health receives core funding from the Wellcome Trust, which provides the platform for the population- and clinic-based research at the Centre.