Liz Kazonza calls for a systematic review of HIV prevention and care strategies with African men and stresses the need for projects that involve these men at the very beginning.
Each day 16,000 people are infected with HIV around the world, the majority through unprotected sex. The cost of high HIV and STI infection rates to African men, families, communities, nations and the international community is enormous and impossible to calculate. Actual numbers of African men with HIV in Europe are unknown. There are different policies regarding HIV prevention, voluntary counselling, testing, care and support for African communities in different European countries.
Recently there has been increased media attention and reports insinuating connections between migrant populations from Africa and transmissible diseases. Such reports are becoming increasingly frequent and mostly deliberately linked to economic impact of HIV and migration, promoting the idea that there is a direct link between migrants, disease and pressure on health care expenses. This has resulted in the creation or tightening of national laws and imposing barriers to access to HIV services to migrants. This is particularly important for African men of uncertain immigration status. African communities in Europe are diverse by way of countries of origin, migration patterns, educational status, religion, culture, sexual orientation and prior access to HIV information and services.
This article will focus on four areas, which are not mutually exclusive to HIV but apply to most areas of disease prevention, health and social care and support for African men: masculinity, equality, prevention approaches and access to care.
Masculinity and HIV – issues for men
Most research from Africa and Europe identifies the prioritisation of involving men to address issues of gender inequalities. The way men are expected to behave by peers is an important consideration to involving men and makes men and women more vulnerable to HIV infection. Many cultures socialise men into believing it is acceptable to take risks particularly sexual ones including having multiple sexual partners. These attitudes about masculinity make it difficult for men to protect themselves and their partners from HIV.
Assumptions of male superiority are currently being challenged by European rules which make it an offence to having non consensual sex and prosecution for any HIV positive person who has unprotected sex with another person resulting in the passing on of HIV to the other person. African men are not responsible for all HIV infections, to assume this would be to repeat the mistake of blaming sections of the community for HIV like gay men, prostitutes, migrants and recently African women.
Pressures faced by African men and women are not equivalent. Men who have sex with men or are bisexual may be particularly vulnerable to HIV and pass on HIV to both their male and female partners because of discrimination and secrecy about sexuality. It is important to recognise that not all men’s behaviour is problematic because most men do not place themselves at risk, Foreman (1999). Many resist negative behaviours associated with these ideas of masculinity, which can be difficult especially for young men. Therefore there is need for positive role models.
Unequal rights to life opportunities, information and HIV testing
The “ myth" of the male as primary provider and leader of the household' is becoming more noticeable especially in Europe where there has been massive mobilisation of women and laws which generally favour women with children in provision of social housing and welfare benefits. Most jobs in cleaning and catering industry are occupied by migrant women enabling them to have financial control and superiority over men.This role reversal sometimes results in tensions including gender-based violence in sexual relationships.
Most HIV interventions have been developed around women mainly focusing on prevention of mother to child HIV infection. Men have until recently were excluded from targeted HIV prevention interventions. Most interventions with African men are in response to either increasing numbers of presenting late for treatment or complex disclosure issues arising from HIV testing in pregnancy programs. It is clearly becoming more evident we need to rethink leadership and development for HIV and AIDS including men.
Prevention of HIV
HIV prevention initiatives need to reflect the lived experience of African men and facilitate procedure and processes that improve their general social, psychological, physical and biological well being. It is important to recognise that unless social conditions of men are improved it becomes difficult for them to engage with HIV prevention.
A harm reduction approach to HIV prevention should apply equally soundly to sexual transmission as it does to injecting drug use. This approach recognises that not everyone will be able to follow the ‘best’ advice at all times, but may be able to follow other options, even if they provide lower levels of protection. When provided with complete and accurate information about their health and how to avoid risk, men are capable of making informed decisions. Initiating dialogue around sexuality of men and women and prevention options for men and women is important.
Information should be factual, up to date and based on research
There is need to undertake research on men e.g. association between circumcision and HIV protection. Many men have raised questions circumcision based on the systematic review of 28 scientific studies, published by the London School of Hygiene and Tropical Medicine, suggesting the skin on the inside of the male foreskin is ‘mucosal’, similar to the skin found on the inside of the mouth or nose and has a high number of Langerhan cells, which are HIV target cells, or doorway cells for HIV.’
Most organisations are changing their approach from treating women's health as a women-only concern and involving men in female health. Underlining messages, which increase vulnerability of men and women to contracting HIV, is important. Highlighting social, biological and physiological factors that make women so vulnerable to HIV infection can facilitate a better understanding of biological and physiological factors that increase vulnerability of men who have other sexually transmitted infections and during penetrative unprotected anal sex.
Development of condom request strategies should be an integral part of emotional support and counseling with African communities. Little is known about what strategies they use, nor the differential effectiveness of specific strategies in persuading male and female partners to use condoms. Reproductive health is an important aspect of STI and HIV prevention for men. Many HIV organizations are expanding their services to discuss broader sexual health and family planning issues and as they do that, they are also realising that without buy in from men, many of their efforts are unlikely to take root.
Men, like women, may be affected by societal gender norms which is why gender based violence is another important aspect of HIV prevention needing attention, Cleaver, (2002). Why would a man with no respect for women listen to women when they say violence towards women is unacceptable? And how can men who profess to respect women not take a stand against the men who do not? These "backward ideas" instilled in the so-called "natural order" of gender inequality is pronounced in many African countries, where it has been complicated by our colonial legacy, fundamental Christianity and African tradition which is long standing and translates to how some African men in Europe behave. Anything that goes against expected male image is avoided e.g. disclosing homosexuality, protecting themselves or partners against sexually transmitted diseases and HIV and AIDS and being faithful to one woman.
The effectiveness of condoms should be made clear in all HIV prevention education and public health interventions. Health promoters would be able to employ hierarchical messages that promote condoms as the best choice but suggest non-penetrative sex and circumcision as fall back options when condom use is not possible. Promotion of knowledge of HIV testing and regular health checks are important considerations in HIV prevention work with men. Promotion and availability of positive role models because of diversity of communities, circumstances of African men in Europe and HIV stigma within African communities is important and needs further development.
Access to care and support
Service access information should be available in places frequented by men; preferably promoted by men to facilitate the exchange of information is a safe environment. Needs based approaches are essential and should be informed by affected communities. There is need to address and lobby issues relating to EU country policies and procedures which might lead to exclusion of men e.g. immigration laws, facilities opening hours, staff attitudes, language support, poverty and other illnesses like mental health. It is also important where possible to ensure staffing of HIV prevention and care services mirrors client groups from reception through to examination room.
Conclusion
There needs to be systematic reviews of current HIV prevention and care interventions with African men to determine what works based on the impact of lives of African men. Men need to be involved at the very beginning of any project plan right through to intervention and evaluation of HIV prevention and care programs. There needs to be more information sharing within the EU around what interventions that successfully work with African men.
References
Cleaver Frances ed (2002) Masculinities Matter! Men Gender and Development Debates, Reflections and Experiences Oxfam Working Papers
Foreman M. (1999) AIDS and Men: Taking Risks or Taking Responsibility, London, New York Panos/Zed Books
UNAIDS (2003) AIDS epidemic update—December 2003
Liz Kawonza is Head of African Services at the Terrence Higgins Trust in the UK.
Email: liz.kawonza@tht.org.uk
Related links:
Terrence Higgins Trust
