Eastern Cape

Site A: a taxi terminal in the business area of a large city in the province. The place is busy because the taxis connect people using rail, road and the sea, coming to the area for work or commerce.

Site B: a taxi terminal in a township located 15 kms from Site A. The taxi rank has many private cars used as taxis – known as `cockroaches’ because there are so many carrying people in the local area.

Site C: is a construction site located about 32 kms from Site A. As well as a population living in informal and low cost housing there are also many temporary workers on the construction site, who move there for work.

KwaZulu-Natal

Site A: this is a taxi terminal in the centre of a town in the north of the province. The town has a population of about 30,000 people. The site serves both local and long-distance travellers. Some of the taxi drivers are, therefore, from other parts of South Africa.

Site B: has three separate areas – a small town (with a population of about 3000 people), a timber yard on the border of the town and a service station/truck stop about 15 km from the town, used by long-distance travellers, including truck drivers.

Ethics statement

The study was approved by the University of KwaZulu-Natal Biomedical Research Ethics Committee (BREC/00005745/2023), the London School Hygiene & Tropical Medicine Ethics Committee (LSHTM Ethics Reference: 29902), the University of Cape Town Ethics Committee (HREC Ref: 496/2023) the Uganda Virus Research Institute Research Ethics committee (GC/127/982) and the Uganda National Council for Science and Technology (HS3099ES). Written (for focus group discussions and individual interviews) and verbal (for informal individual conversations and natural group discussions) informed consent was taken from all participants before they engaged in an activity.

Rapid ethnographic assessment method

The rapid ethnographic assessment is an approach using a mix of qualitative methods in a set sequence, designed to move from a broader to a more specific understanding of the topic being addressed. Through this approach we collected qualitative data that is both focused on the whole community context and also specifically on men and their HIV-prevention choices. The methods are described in more detail in S2 Text. The first rapid ethnographic assessment took place from 28^th November 2023, and the last one was concluded by 30^th July 2024.

The rapid ethnographic assessment methodology comprises of a set of structured activities presented in Table 1 below, aimed at gathering a comprehensive perspective on the area of study and the communities living there, in response to key research questions about the settings. The rapid ethnographic assessment approach we used is conducted in a limited timeframe of 15 days [28] by a team of six to eight research assistants, fluent in the local languages and trained in the data collection methods. This data collection methodology was standardized across the study areas to include observations, spiral or transect walks, individual conversations, in-depth interviews (IDIs) and natural group discussions (NGDs) and focus group discussions (FGDs) [29,30]. To facilitate community entry the research teams in the respective places engaged the Community Advisory Boards overseeing the chosen research sites for guidance on appropriate community entry specific to the sites concerned [31,32]. This was followed by seeking the relevant permissions from the local leadership, including traditional, political or community leaders depending on the area concerned [33], before data collection commenced.

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Table 1. Research activities, key questions and methods used.

https://doi.org/10.1371/journal.pgph.0005213.t001

Data analysis

Data analysis was done manually using a framework analysis approach [34]. The aim and objectives which informed the design of the rapid ethnographic assessment were used to define initial thematic areas, with additional themes added if new ideas were identified from the study findings. These themes were shared and discussed across the sites to arrive at a shared coding framework. Following the identification of themes, indexing (coding) and charting (copying and pasting data according to thematic areas) were done simultaneously at each site. Mapping (visual display of data) was then done to allow researchers to identify patterns, associations, and concepts. Descriptive and analytical memos could then be produced from these charts. Each of the study teams in the three sites conducted regular staff debriefing sessions to synthesize and contextualise site specific findings. These meetings allowed for robust discussions at each site. In addition, weekly meetings by the social science leads (TM, SN, MM, JS) ensured that similarities and differences across the three sites were discussed.

Thematic content analysis was used to analyse and manage the interpretation of the data – working across all the sites using a shared coding framework. All interview and discussion transcripts and field notes, diagrams and maps were included for analysis. Each team produced an overview report of the findings from each site, for use by clinic team members prior to the commencement of the trial. For this paper the teams focused on the coded data on men’s sexual behaviour and their HIV prevention choices.

Findings

The data for this paper are drawn from 50 group discussions (27 FGDs and 23 NGDs), 61 in-depth interviews and 297 informal conversations with men and women, as well as observational notes from the sites in South Africa and Uganda.

Sexual behaviour and HIV risk perceptions

Being away from home, boredom and consuming alcohol were some of the reasons men gave for engaging in sex with casual, and sometimes, multiple partners. In the taxi ranks we found that some of the women from whom men got their evening meal also provided them with sex. “We cook for them, and we give them sex” (EC-Site B, FGD). At the fishing sites some of the young women serving in bars and restaurants made an income from providing sex to customers, with bar owners exploiting this by paying low wages to the women and keeping staff for limited time periods because `new’ women would attract customers. These women in both Uganda and South Africa would not necessarily consider themselves sex workers. There were other women in each site who provided sexual services as their main occupation often operating from particular areas in each site. One of the taxi drivers in KwaZulu-Natal explained the behaviour of men like him:

“You find that we are sitting and bored and drinking alcohol, ooh yes we do drink, after drinking alcohol we get aroused, I then move to a place where I can find someone to have a nice time with, not that anyone is forcing you of course, we are old enough to do things because we want to do them” (KZN, Site A, IDI).

A construction worker in the Eastern Cape gave a similar explanation:

“Girls from the bar, we do not use condoms because these things just happen abruptly as we are drunk at the time you just take her to your place, it is the first time meeting her, she is from around the place, so you do not know her fully, the way she carries herself, her behaviour. You simply take her home and sleep with her and obviously without using a condom, so that is how these things happen, you are then at risk of contracting HIV/AIDS.” (EC-Site C, IDI).

Nearly all the men we spoke to preferred sex without a condom because of increased sexual pleasure, which they considered a condom interfered with. One man from Eastern Cape explained that `the plastic can waste the excitement’ (EC-Site C, FGD). When asked about condom use, another man from Eastern Cape stated,

“Most men do not; men have this saying ‘ayityiwa sweets ezine phepha’ (you do not eat a sweet with its paper on). Therefore, they cannot use a condom because they do not enjoy sex.” (EC Site C, IDI).

Men in all sites used similar language to explain why they did not like condoms. The general sentiment pointed towards a shared recklessness for inconsistent condom use and multiple sexual partnerships. This is further illustrated from a quote from a man participating in a focus group discussion in Masaka who used the same example of not eating a sweet in its wrapping, as the one from Eastern Cape, above:

“you can get a partner and choose to be with her, you know the youth have a motto that `sinunira sweet mu kaveera’ implying that they never want to use condoms to maximize sexual pleasure.” (Masaka Site B, FGD).

Interestingly, the reputation of men for taking risks, something respondents in Uganda said was associated with men in fishing communities, seemed to fuel high-risk sexual behaviour, as if they had a reputation to maintain. A few men in South Africa rationalised this behaviour as keeping their sexual appetite high for when they were with their wives. They described this behaviour as looking after their `axe’ so it can be used effectively when at home. A man from Eastern Cape explained: `If you don’t sharpen your axe, it stops cutting, it will go blunt, you will be with your wife at home day and night and your axe won’t work, it won’t come up (erection).’ (EC-Site B, FGD).

Some men did talk about condom use, indeed the same man who talked about the condom spoiling the excitement, mentioned above, said that he did sometimes use condoms, explaining how he made that decision:

“You know as men we gauge women. Sometimes when having sex and the girl asks about a condom you would lie and say that you don’t have it, knowing very well that you have it in your pocket. And [then with] some women you would rather go knock at your neighbours and ask for a condom. That is how it is. You don’t just risk and go without it with some women.” (EC-Site C, FGD).

He went on to observe that this method is not always reliable because one could not be sure a woman was not living with HIV.

The women who sold sex commercially at each site also made choices about the risks they took with the men, although when money was short, they may be forced to accept condomless sex in order to earn a higher rate. However, many of these women were familiar with oral PrEP having been targeted by HIV prevention organisations and were using it to protect themselves from HIV acquisition, but understood that condomless sex exposed them to the risk of other sexually transmitted infections. A female sex worker from Masaka explained the complexity of using condoms, suggesting that PrEP offered a better protection option:

”We have to protect ourselves against HIV infections and I think a person has to take PrEP to protect against the HIV infections […] When a person comes and wants unprotected sex you can’t insist on protected sex. We use condoms but sometimes the men pierce them and, in the end, semen enters your body. If you are on PrEP you are safe. Condoms protect us against infections such as syphilis and candidiasis. Even if PrEP is available if a person doesn’t want to take then you can’t force but those who love their lives will take them.” (Ma-Site A, FGD).

Another woman at the same site illustrated the challenges of negotiating condom use with men who were reluctant to use them:

“… a circumcised man […] may come and insist on live (condomless) sex because he is circumcised claiming he is safe, yet he is infecting you. I still insist that let us stick to two things, condoms and PrEP. Do not listen to someone if his protection defence is because he is circumcised.” (Ma-Site B, FGD).

These women were conscientious about their own sexual health; they understood the risks that their livelihood posed. Sex workers in South Africa were said to always have condoms on them One man from KwaZulu-Natal noted:

“We do buy sex but we do not make a mistake, they always carry their condoms (sex workers),it is always up to a person if you decide not to use a condom especially if you know that you are already infected with HIV and you do not care. But if you know that you do not have HIV you always use a condom, as for me I always make sure of that.” (KZN-Site A, IDI).

Relying on women to manage HIV-prevention may be linked to a sense that women had more ready access to prevention methods and healthcare in general.

Access to healthcare

Men in all the sites explained that they associated health clinics with women and children. Taxi drivers in Eastern Cape, for example, complained that clinics: `prioritise new mothers and those who come for family planning’. When asked about the services they are aware of in their area, the men in KwaZulu-Natal said that where health care services were offered, they did not feel as if those services were intended for them.

“Yes, there are people who came here. I do not remember the month but it was on women-based campaigns. It is unusual here at the rank to find a place that offers some assistance (for men).” (KZN, Site A, IDI).

The men also explained how distance and a lack of time impeded access:

“We do have a public clinic here in town, but it’s very far, and it’s always packed, you can queue in the line there for 4 to 5 hours. There is no care in that clinic.” (EC-Site A, IDI).

“…What I’m trying to say is that we are defaulting because health [centres] are far from us. […] that brother is saying someone once died here. Another person was driving and parked and died inside his taxi. […] he died sitting in his taxi. Another person was driving, he parked and said, “I’m not feeling well”. That was the last time we heard from him. The car was parked in the road” (EC-Site B, FGD).

There were similar concerns among the taxi drivers in KwaZulu-Natal, with men attributing their lack of healthcare access to their busy work schedule:

“Taxi drivers do not have time. You see taxis do not stay here (at the terminal) for very long, you find that if you try to go say to the mobile clinic (on the outside of the town), as soon as you get there you can get called back because your taxi is now full and you need to deliver the passengers. When you get to the destination, you are called back again to the terminal.” (KZN, Site A, IDI)

Fishermen in Uganda also explained how clinic location, opening times and queues impeded their health care access, including their access to health care information. From a group discussion in MA, Site B, one participant echoed the sentiments about women being more likely to access services: `The people who test more are the women, and the reason is that by the time those services come to the area, they [women] are not busy.’ (MA, Site B, FGD).

This view was shared by a health care worker in another group discussion in MA, Site B: `I see that women take responsibility for themselves and their children to seek medical help early as compared to men’. (MA, Site B, FGD).

Knowledge of PrEP and HIV prevention choices

None of the men in any of the sites that we spoke to was using PrEP at the time of the study. Some knew of oral PrEP but thought it was for women (to protect a child in pregnancy). As an introduction to the rapid assessment, the study team shared information on different types of PrEP, as well as the types of care available for people living with HIV. We found that PrEP (used by women) was often confused with anti-retroviral therapy or post-exposure prophylaxis. When told about oral PrEP, one man from Eastern Cape observed:

“No this is news to me, I only heard about it from pregnant woman that they should take the pill so that they do not transfer the virus to the unborn baby, but this is nice to hear [that it is] also even for men, because men do not trust themselves.” (EC-Site A, IDI).

The reason men gave for not using oral PrEP was because of a lack of information, largely because, as noted above, they did not go to health centres or clinics.

“…I usually hear about PrEP from females, saying they are going to the clinic to get PrEP. So, I did not know that men are also allowed to take PrEP.” (EC Site C, FGD).

Consequently, due to the lack of knowledge and misinformation about PrEP, there was some confusion between types of HIV prevention and treatment (because both anti-retroviral and PrEP pills were seen as being the same). A local health worker at Site A in Masaka, talking about the fishermen, said that:

“They have a perception that PrEP is a virus that when you take it you get infected and that the drug was manufactured with a virus and that the moment you take it you get infected [...]. Those are the perceptions they have that they [unspecified] want to reduce the people so that they die in plenty.” (Ma-Site A, IDI).

The main concern the men had was that if they were seen taking pills, then it would be assumed that they were living with HIV. The idea of a long-acting injection that provided protection from HIV was welcomed by many of the respondents when they were told about it:

“PrEP tablets may lead to stigma, and you can end up losing your friends as they may be tempted to think that you are HIV positive. But with injectable no one will ever know about your presence on injectable PrEP. It’s always between you and the health worker.” (Ma-Site A, FGD).

A local leader in Masaka commented

“Based on myself, I can’t go for tablets when I have an alternative of injection […] If the injection is not daily, and if I can get it at least for three months and am sure that it’s preventive, I rather get an injection but not tablets. And even in normal sickness people prefer using injections over tablets.” (Ma-Site B, IDI).

None of the men we spoke to in any of the sites had heard of injectable PrEP before the introduction of the study. However, health workers at all the sites mentioned that people, although not necessarily the mobile men, had heard about an injection in the media and were asking when it would be available. There were some concerns. For example men from Site B in KwaZulu-Natal as well as from Site A in Eastern Cape voiced reservations about LA-PrEP because of the fear of injections and the distaste they felt over someone touching their bottom to administer the dose. However, they thought it would be a good option for men like them who travelled and could not carry pills with them, because the pill bottles rattled, revealing to those around them that they were carrying some form of medication, which they assumed people would associate with HIV treatment.

In the taxi rank in Eastern Cape several men said that injectable PrEP could become the preferred method of preventing HIV because men were not going to change their sexual behaviour. There was general optimism that this form of PrEP would be a game changer for men in general and for those who were mobile for work because they were used to engaging in risky sex. However, there was some misinformation about the benefits of taking PrEP:

“…It is said that this PrEP makes you sexually active, you always need a woman when you take PrEP, that is the reason we are interested in hearing more about it because we know….as men, we know when we talk of PrEP…laughter…I’m sure I’m not the only one who knows about this.” (EC Site A, FGD).

In summary, mobile men in our study did not tend to access health care facilities because they perceived them as unwelcoming to males. They did not like the long queues because the nature of the men’s work did not afford them time to wait to access health care. These men often engaged in sex with casual partners, without using any form of HIV protection. A dislike of condoms because of the effect on their sexual pleasure and a wariness about taking pills for prevention because of the association with HIV treatment, as well as being viewed as a method for women to use, led to a general reluctance from men to take up these prevention methods. However, the idea of a long-acting injection, which meant that they would not have to take pills and could have condomless sex, was viewed with enthusiasm because of the promise that the method held to provide protection from HIV without having to change their sexual behaviour.

Strengths and limitations

A strength of our study is the large number of men we were able to gather detailed information from on HIV prevention. However, these men were by definition mobile and were not always available for follow up conversations. The time spent talking to some men was often very limited because they were in hurry and that may have influenced some of the responses. However, engaging with natural groups of men in their place of work or leisure enabled us to adapt our approach to men’s lifestyles and schedules for data collection. The views and perception of members of these communities who were less interested in participating may have been underrepresented despite efforts to select across all sectors of the community. Lastly, more time in the communities at the respective sites, beyond the 15 days would have allowed for a larger number of conversations about perceptions on PrEP and HIV prevention, however the approach is thorough and designed to gain an overview of a setting prior to the commencement of a trial, and further social science research (which is embedded in the trial) [30].