title: 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.
authors.affiliation: a HIV/AIDS, STIs and TB Programme , Human Sciences Research Council (HSRC) , Durban , South Africa.
authors.forename: Jeremiah
authors.initials: J
authors.lastname: Chikovore
authors.affiliation: b Human and Social Development , HSRC , Durban , South Africa.
authors.forename: Natasha
authors.initials: N
authors.lastname: Gillespie
authors.affiliation: c Faculty of Medicine , University of Southampton , Southampton , UK.|d Faculty of Social, Human and Mathematical Sciences , University of Southampton , Southampton , UK.|e Africa Centre for Population Health , University of KwaZulu Natal , Mtubatuba , South Africa.|f Research Department of Infection and Population Health , University College London , London , UK.
authors.forename: Nuala
authors.initials: N
authors.lastname: McGrath
authors.affiliation: g INSERM, ISPED, Centre INSERM U1219 - Bordeaux Population Health, Université de Bordeaux , Bordeaux , France.
authors.forename: Joanna
authors.initials: J
authors.lastname: Orne-Gliemann
authors.affiliation: e Africa Centre for Population Health , University of KwaZulu Natal , Mtubatuba , South Africa.
authors.forename: Thembelihle
authors.initials: T
authors.lastname: Zuma
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D001294:Attitude to Health; D030881:Disclosure; D005260:Female; D017144:Focus Groups; D015658:HIV Infections / Q000175:diagnosis / Q000517:prevention & control* / Q000523:psychology*; D006296:Health Services / Q000706:statistics & numerical data*; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D057228:Masculinity; D008403:Mass Screening; D008571:Men / Q000523:psychology*; D010342:Patient Acceptance of Health Care / Q000208:ethnology / Q000523:psychology*; D036301:Qualitative Research; D012725:Sexual Behavior; D057545:Social Stigma; D012959:Socioeconomic Factors; D013019:South Africa
chemical_list: D019380:Anti-HIV Agents
keywords: HIV; Masculinity; South Africa; qualitative; treatment as prevention