Citation: Mills EJ, Beyrer C, Birungi J, Dybul MR (2012) Engaging Men in Prevention and Care for HIV/AIDS in Africa. PLoS Med 9(2): e1001167. https://doi.org/10.1371/journal.pmed.1001167
Published: February 7, 2012
Copyright: © 2012 Mills et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: No specific funding was received for writing this article.
Competing interests: CB is a member of the PLoS Medicine Editorial Board. All other authors have declared that no competing interests exist.
Abbreviations: ART, antiretroviral therapy; MSM, men who have sex with other men
Provenance: Not commissioned; externally peer reviewed.
- The HIV/AIDS response in Africa has always had a gender focus; targeted efforts have reduced the impact of the epidemic on women and children.
- The response has been far less successful for the treatment of men: there is less ART coverage of men than women in Africa, and men typically have higher mortality. Men also tend to present at clinic with advanced disease and are more likely to be lost to follow-up.
- Yet, efforts to understand men's healthseeking behaviour are poorly understood in the AIDS epidemic, and encouraging men to get tested and treated is a major challenge, but one that is poorly recognized.
- We review the emerging evidence and we call for a balanced approach to gender programming in an effort to involve both men and women in treatment and prevention.
Antiretroviral therapy (ART) saves lives and prevents new HIV/AIDS infections . Successful efforts to increase the number of people receiving ART create important public health challenges, some of which may be considered counter-intuitive. One of the largest challenges for ART provision has been targeting populations most affected by HIV/AIDS and most vulnerable to the effects of the disease. In Africa, the focus of the epidemic has historically been on women and children. Women are considered to be particularly vulnerable to HIV infection in this setting because of biological factors, their reduced sexual autonomy, and men's sexual power and privilege over them. –. This understanding has led HIV/AIDS public health prevention and treatment campaigns to focus on women and children in this setting. As a result, men have received considerably less attention in the epidemic  and receive less targeted HIV prevention and treatment programs .
Targeting men in prevention and treatment, however, may have a large impact on mortality, new infections, and the economic impact of HIV/AIDS in Africa. In the wake of the HPTN 052 trial results, demonstrating 96% (95% confidence interval, 73%–99%) efficacy of prevention in discordant couples with earlier ART treatment initiation, engaging greater numbers of men with HIV in treatment could have important prevention benefits for women and girls, and for primary prevention of vertical transmission .
Neglect of Men in HIV Prevention and Treatment Campaigns
In the last half-decade, there has been discussion over the need to actively engage men in sub-Saharan Africa in HIV prevention campaigns. Several randomized trials in South Africa have examined interventions aimed at male behavior change –. Further work has come from the social science disciplines, where researchers and gender advocates have created gender-focused HIV prevention frameworks and contextualized the role of men in contributing to the epidemic ,,. Although much of this work has examined attitudes and behaviors, there is emerging recognition from a number of epidemiological sources that men in sub-Saharan Africa face important challenges in terms of HIV vulnerability, engagement and retention in care, and access to ART that affect mortality ,. Taken together, the evidence indicates that men are under-represented in HIV testing, treatment, and care, and this likely has a direct impact on outcomes of care –.
While public health efforts have been aimed at women, particularly child-bearing women (e.g., HIV testing, care, and treatment opportunities provided through antenatal care services), scale-up efforts are hindered by the differences in health-seeking behaviors between men and women . For instance, sickness may be seen as a sign of weakness for many men, and this perception has resulted in a reluctance of care-seeking among men . There is also evidence indicating that men may feel that they have been caught at their hidden sexual behaviors and so they avoid HIV testing . Additionally, employment-related migration will keep men away from their partner and families for long time periods, and this absence may make them more vulnerable to HIV infection due to sexual exposure, drug and alcohol use, and delinkages with local health services . The reality that men are less likely to seek health care is intimately linked to perceptions of masculinity, and is generally considered to be part of the same phenomenon that drives multiple partnering, violence against women, substance use, and homophobia among men ,.
There is now also a growing appreciation that the HIV/AIDS epidemic in Africa is driven by complex and poorly understood sexual dynamics that include, among others, concurrent partner relationships and multiple partner relationships involving both males and females –. The available evidence indicates that infection is equally balanced between males and females in most heterosexual settings .
Failing to engage men in HIV prevention and treatment may also have an impact on household family income. In Africa, men are typically the larger income-generators, often engaged in employment outside of the home, whereas women are more likely to be engaged in economic activities closer to home as well as child caring. If the head male member contracts HIV and does not receive the appropriate care, ill health or death of this individual can severely impact household family income.
While our discussion here is predominantly focused on heterosexual men, we cannot ignore that men who have sex with other men (MSM) are one of the most difficult groups to target in prevention and treatment campaigns in Africa. Data on the magnitude of MSM or the prevalence of HIV in this population are sparse . The recent crackdown on MSM in Uganda, where the government petitioned a law before parliament to make MSM sexual activities illegal, potentially punishable by death for those who are HIV positive, demonstrates that certain male groups require specific care and support . The law, largely condemned around the world, also placed pressure on HIV/AIDS service providers, as anyone, including organizations, aware of homosexual activity and failing to report the act could be punished with up to three years of imprisonment. With the popular support the bill has received, HIV/AIDS service organizations have been challenged to provide strong advice to their employees on how to treat MSM patients. Similar legal and cultural oppression of MSM occurs in other African countries.
The Magnitude of HIV/AIDS-Related Mortality by Gender
The gender differences inherent in the health-seeking behaviors of men and women, and the historical gender-specific efforts in HIV-related public health campaigns in this region, impact health outcomes, including mortality ,,. For instance, recent cohort studies conducted among individuals starting ART in sub-Saharan Africa have indicated that men tend to access ART at a later disease stage than women, and the risk of mortality once on ART is much higher for men than women, even when adjusting for disease state ,. Specifically, in Uganda, evidence from a large, nationally representative cohort study indicates that men are (hazard ratio, HR) 1.43 (95% confidence interval: 1.31–1.57) times more likely to die than women , and in South Africa, evidence from a large cohort study indicates that men are 1.47 (HR, 95% confidence interval: 1.27–1.72) times more likely to die than women . Using these estimates, and demographic input assumptions and population estimates ,, HIV prevalence –, and the number of individuals receiving ART –, we can develop a simple projection model to estimate HIV/AIDS-related mortality by gender for the two counties. Assuming that these estimates remain constant, a crude mortality projection from 2004–2015 indicates that the cumulative number of national HIV/AIDS-related deaths for those aged 15–49 years is much higher among males when compared to females in both Uganda (475,986 cumulative number of deaths for males versus 204,674 cumulative number of deaths for females) and South Africa (2,488,286 cumulative number of deaths for males versus 1,169,494 cumulative number of deaths for females). (Please contact the primary author for a complete description of the model assumptions.)
Although there have been efforts to involve men at antenatal clinics, these have had mixed results in terms of HIV prevention . There are examples of HIV prevention programs in Africa that have intentionally targeted men in their campaigns to change sexual behaviors –. However, they are predominantly concerned with primary prevention, and rarely consider treatment interventions. A small body of evidence is emerging indicating that programs integrated into the workplace and programs that offer peer education may be successful at engaging African men in HIV testing, care, and treatment .
Funding agencies should recognize that males and females are both severely affected by the epidemic in differing ways, and should plan for interventions that engage both men and women. Funding agencies, such as the US President's Emergency Plan for AIDS Relief (PEPFAR), frequently allocate funding according to priority groups, particularly women and children . Targeted and sustainable funding may result in important lessons learned.
Targeting specific populations for ART treatment and care can have important residual effects on preventing transmission to other populations. The HPTN 052 trial confirmed findings from observational studies that ART has a large preventive impact on sexual partners . Given the economic reality, scaling up access to ART as a prevention strategy will be a challenge due to costs, human resources constraints, and prioritizing recipients; targeting those individuals and groups who are most likely to transmit the virus, core transmitters, may be a first step in using ART treatment as prevention in a scaled up manner. It is also likely that male circumcision clinics, slowly growing in number in sub-Saharan Africa, would be ideal venues to test men for HIV, and provide them with appropriate referrals for care and treatment. Mobile approaches to testing targeted at venues, including work spaces, frequented by men may also have significant impacts on increasing male engagement in prevention and treatment. This approach has been demonstrated by the success of HPTN 043 (Project Accept) reported in 2011, that markedly increased male acceptance of testing in four countries (South Africa, Zimbabwe, Tanzania, and Thailand) . Targeted treatment of all individuals who are HIV positive and in a relationship or sexually active will reduce their viremia and reduce their potential to infect others .
The epidemiological evidence is accumulating, and indicates that males in sub-Saharan Africa are not accessing HIV services as often as their female counterparts, and as a result, men have worse outcomes of care, including mortality. Funding organizations need to recognize the social and health impacts associated with not engaging men in primary and secondary HIV prevention campaigns. Programmatic efforts should account for this disparity, and recognize that it may be necessary to seek out men for HIV testing, care, and ART in variety of settings, and through mechanisms that that take into consideration the local culture and gender roles in partnerships, sex, and health.
Conceived and designed the experiments: EM CB JB MD. Performed the experiments: EM CB JB MD. Analyzed the data: EM CB JB MD. Contributed reagents/materials/analysis tools: EM CB JB MD. Wrote the first draft of the manuscript: EM CB JB MD. Contributed to the writing of the manuscript: EM CB JB MD. ICMJE criteria for authorship read and met: EM CB JB MD. Agree with manuscript results and conclusions: EM CB JB MD.
- 1. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, et al. (2011) Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 365: 493–505.
Joint United Nations Programme on HIV/AIDS UPF, UN Development Fund for Women (2004) Women and HIV/AIDS: confronting the crisis. New York: UN Population Fund.
- 3. Krishnan S, Dunbar M, Minnis A, Medlin C, Gerdts C, et al. (2008) Poverty, gender inequities, and women's risk of human immunodeficiency virus/AIDS. Ann N Y Acad Sci 1136: 101–110.
- 4. Ojikutu B, Stone V (2005) Women, inequality, and the burden of HIV. N Engl J Med 352: 649–652.
- 5. Higgins J, Hoffman S, Dworkin S (2010) Rethinking gender, hetersexual men, and women's vulnerability to HIV/AIDS. Am J Public Health 100: 435–445.
- 6. Gupta G (2002) How men's power over women fuels the HIV epidemic. BMJ 324: 183–184.
- 7. Exner T, Gardos P, Seal D, Ehrhadrt A (1999) HIV sexual risk interventions with hetersexual men: the forgotten group. AIDS Behaviour 3: 347–358.
- 8. Kalichman SC, Cain D, Eaton L, Jooste S, Simbayi LC (2011) Randomized clinical trial of brief risk reduction counseling for sexually transmitted infection clinic patients in Cape Town, South Africa. Am J Public Health 101: e9–e17.
- 9. Kalichman SC, Simbayi LC, Cloete A, Clayford M, Arnolds W, et al. (2009) Integrated gender-based violence and HIV Risk reduction intervention for South African men: results of a quasi-experimental field trial. Prev Sci 10: 260–269.
- 10. Kalichman SC, Rompa D, Cage M (2005) Group intervention to reduce HIV transmission risk behavior among persons living with HIV/AIDS. Behav Modif 29: 256–285.
- 11. Dunkle KL, Jewkes RK, Nduna M, Levin J, Jama N, et al. (2006) Perpetration of partner violence and HIV risk behaviour among young men in the rural Eastern Cape, South Africa. AIDS 20: 2107–2114.
- 12. Jewkes R, Nduna M, Levin J, Jama N, Dunkle K, et al. (2008) Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial. BMJ 337: a506.
- 13. Dworkin S, Dunbar M, Krishnan S, Hatcher A, Sawires S (2011) Uncovering tensions and capitalizing on synergies in HIV/AIDS and antiviolence programs. Am J Public Health 101: 995–1003.
- 14. Dunkle K, Jewkes R (2007) Effective HIV prevention requires gender-transformative work with men. Sex Transm Infect 83: 173–174.
- 15. May M, Boulle A, Phiri S, Messou E, Myer L, et al. (2010) Prognosis of patients with HIV-1 infection starting antiretroviral therapy in sub-Saharan Africa: a collaborative analysis of scale-up programmes. Lancet 376: 449–457.
- 16. Johannessen A (2011) Are men the losers of the antiretroviral treatment scale-up? AIDS 25: 1225–1226.
- 17. Hawkins C, Chalamilla G, Okuma J, Spiegelman D, Hertzmark E, et al. (2011) Sex differences in antiretroviral treatment outcomes among HIV-infected adults in an urban Tanzanian setting. AIDS 25: 1189–1197.
- 18. Braitstein P, Brinkhof MW, Dabis F, Schechter M, Boulle A, et al. (2006) Mortality of HIV-1-infected patients in the first year of antiretroviral therapy: comparison between low-income and high-income countries. Lancet 367: 817–824.
- 19. Braitstein P, Boulle A, Nash D, Brinkhof MW, Dabis F, et al. (2008) Gender and the use of antiretroviral treatment in resource-constrained settings: findings from a multicenter collaboration. J Womens Health (Larchmt) 17: 47–55.
- 20. Ochieng-Ooko V, Ochieng D, Sidle JE, Holdsworth M, Wools-Kaloustian K, et al. (2010) Influence of gender on loss to follow-up in a large HIV treatment programme in western Kenya. Bull World Health Organ 88: 681–688.
- 21. Muula AS, Ngulube TJ, Siziya S, Makupe CM, Umar E, et al. (2007) Gender distribution of adult patients on highly active antiretroviral therapy (HAART) in Southern Africa: a systematic review. BMC Public Health 7: 63.
- 22. Mane P, Aggleton P (2001) Gender and HIV/AIDS: what do men have to do with it? Current Sociology 49: 23–37.
United Nations Integrated Regional Information Networks (IRIN) (2006) Uganda: men's union encourages men to be more open about HIV. United Nations Integrated Regional Information Networks.
- 24. Epstein H, Swidler A, Gray R, Reniers G, Parker W, et al. (2010) Measuring concurrent partnerships. Lancet 375: 1869; author reply 1870.
- 25. Eyawo O, de Walque D, Ford N, Gakii G, Lester RT, et al. (2010) HIV status in discordant couples in sub-Saharan Africa: a systematic review and meta-analysis. Lancet Infect Dis 10: 770–777.
- 26. Padian N, Manian S (2011) The concurrency debate: time to put it to rest. Lancet 378: 203–204.
- 27. van Griensven F, de Lind van Wijngaarden JW, Baral S, Grulich A (2009) The global epidemic of HIV infection among men who have sex with men. Curr Opin HIV AIDS 4: 300–307.
- 28. Alsop Z (2009) Ugandan bill could hinder progress on HIV/AIDS. Lancet 374: 2043–2044.
- 29. Ingle SM, May M, Uebel K, Timmerman V, Kotze E, et al. (2010) Differences in access and patient outcomes across antiretroviral treatment clinics in the Free State province: a prospective cohort study. S Afr Med J 100: 675–681.
- 30. Mills EJ, Bakanda C, Birungi J, Chan K, Hogg RS, et al. (2011) Male gender predicts mortality in a large cohort of patients receiving antiretroviral therapy in Uganda. J Int AIDS Soc 14: 52.
United States Agency for International Development (2009) Health Policy Initiative. AIM: a computer program for making HIV/AIDS projections and examining the demographic and social impacts of AIDS. Available: http://data.unaids.org/pub/Manual/2009/20090414_aim_manual_2009_en.pdf. Accessed 28 December 2011.
United States Agency for International Development (USAID) (2007) Health Policy Initiative. DemProj: a computer program for making population projections. Available: http://data.unaids.org/pub/Manual/2007/demproj_2007_en.pdf. Accessed 28 December 2011.
Health Systems Trust (2011) Recently updated indicators. HIV prevalence (%) (age 15–49). Available: http://indicators.hst.org.za/healthstats/293. Accessed 28 December 2011.
Joint United Nations Programme on HIV/AIDS (UNAIDS) (2008) Epidemiological fact sheet on HIV and AIDS: South Africa. Available:. http://apps.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008_ZA.pdf. Accessed 10 January 2012.
Joint United Nations Programme on HIV/AIDS (UNAIDS) (2008) Epidemiological fact sheet on HIV and AIDS: Uganda. Available:. http://apps.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008_UG.pdf. Accessed 10 January 2012.
World Health Oganization (WHO), Joint United Nations Programme on HIV/AIDS (UNAIDS), United Nations Children's Fund (UNICEF) (2010) Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Progress report 2010. Available: http://www.who.int/hiv/pub/2010progressreport/report/en/index.html. Accessed 28 December 2011.
World Health Oganization (WHO), Joint United Nations Programme on HIV/AIDS (UNAIDS), United Nations Children's Fund (UNICEF) (2009) Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Progress report 2009. Available: http://www.who.int/hiv/pub/2009progressreport/en/. Accessed 28 December 2011.
World Health Oganization (WHO), Joint United Nations Programme on HIV/AIDS (UNAIDS), United Nations Children's Fund (UNICEF) (2008) Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Progress report 2008. Available: http://www.who.int/hiv/pub/2008progressreport/en/index.html. Accessed 28 December 2011.
World Health Oganization (WHO), Joint United Nations Programme on HIV/AIDS (UNAIDS), United Nations Children's Fund (UNICEF) (2007) Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Progress report 2007. Available: http://www.who.int/hiv/pub/2007progressreport/en/index.html. Accessed 28 December 2011.
World Health Oganization (WHO), Joint United Nations Programme on HIV/AIDS (UNAIDS), United Nations Children's Fund (UNICEF) (2006) Progress on global access to HIV antiretroviral therapy: a report on 3 by 5 and beyond. Available: http://www.who.int/hiv/pub/2006progressreport/en/. Accessed 28 December 2011.
Barker G, Ricardo C, Nascimiento M (2007) Engaging men and boys in changing gender-based inequity in health: evidence from programme interventions. http://www.who.int/gender/documents/Engaging_men_boys.pdf. Geneva: World Health Organization.
- 42. Hutchinson S, Weiss E, Barker G, Sagundi M, Pulerwitz J (2004) Involving young men in HIV prevention programs: operations research on gender-based approaches in Brazil, Tanzania, and India. Horizons Rep Dec 1–6.
- 43. Peacock D, Levack A (2004) The men as partners program in South Africa: reaching men to end gender-based violence and promote sexual and reporductive health. Int J Mens Health 3: 173–188.
Sonke Gender Justice (2007) One Man Can workshop activities: talking to men about gender, sexual and domestic violence, and HIV/AIDS. Available http://www.genderjustice.org.za/onemancan/download-the-toolkit/2.html. Accessed 28 December 2011.
Sonke Gender Justice (2008) One Man Can: working with men—essential to reducing the spread and impact of gender based violence and HIV and AIDS in Southern Africa. Available: http://www.genderjustice.org.za/onemancan/images/publications/factsheet/factsheet_eng.pdf. Accessed 28 December 2011.
- 46. Jewkes R, Nduna M, Levin J, Jama N, Dunkle K, et al. (2006) A cluster randomized-controlled trial to determine the effectiveness of Stepping Stones in preventing HIV infections and promoting safer sexual behaviour amongst youth in the rural Eastern Cape, South Africa: trial design, methods and baseline findings. Trop Med Int Health 11: 3–16.
- 47. Kuwane B, Appiah K, Felix M, Grant A, Churchyard G (2009) Expanding HIV care in Africa: making men matter in Johannesburg. Lancet 374: 1329.
- 48. Birungi J, Mills EJ (2010) Can we increase male involvement in AIDS treatment? Lancet 376: 1302.
- 49. Sweat M, Morin S, Celentano D, Mulawa M, Singh B, et al. (2011) Community-based intervention to increase HIV testing and case detection in people aged 16–32 years in Tanzania, Zimbabwe, and Thailand (NIMH Project Accept, HPTN 043): a randomised study. Lancet Infect Dis 11: 525–532.
- 50. Lima VD, Johnston K, Hogg RS, Levy AR, Harrigan PR, et al. (2008) Expanded access to highly active antiretroviral therapy: a potentially powerful strategy to curb the growth of the HIV epidemic. J Infect Dis 198: 59–67.