“If you don’t take a stand for your life, who will help you?”: Men’s engagement in HIV care in Kwazulu-Natal, South Africa.

Abstract

The needs of South African men with HIV may often be overlooked in the provision of HIV services, leading to care programs that do not adequately serve the unique needs of male patients. Additionally, norms of masculinity guide men’s behaviors as they navigate health decision-making and the healthcare systems. The aim of this study is to examine how masculinity influences healthcare access and utilization in South Africa, and to identify opportunities for interventions. The qualitative study took place at one primary health care clinic in a peri-urban township in KwaZulu-Natal, South Africa. In-depth individual interviews were conducted with 21 HIV-infected men recruited from the study clinic. Direct observations of the clinic waiting area were conducted to provide context. Data were analyzed using a grounded theory-informed approach involving memo writing and thematic exploration with data coding. On average, participants were 42 years old and had been on ART for 3.6 years. Participants expressed a range of ways in which masculine ideals and identity both promoted and inhibited their willingness and ability to engage in HIV care. Notions of masculinity and social identity were often directly tied to behaviors influencing care engagement. Such engagement fostered the reshaping of identity around a novel sense of clinic advocacy in the face of HIV. Our findings suggested that masculinities are complex, and are subject to changes and reprioritization in the context of HIV. Interventions focusing on reframing hegemonic masculinities and initiating treatment early may have success in bringing more men to the clinic.

What Role Do Masculine Norms Play in Men’s HIV Testing in Sub-Saharan Africa?: A Scoping Review

“…In addition, men feared HIV testing revealing their infidelity in Lesotho [29], Ugandan mining communities [30, 31], rural Zimbabwe [37], and rural South Africa [33]—fearing subsequent abandonment and losing their masculine role as husband. Studies from Malawi, South Africa, Uganda, and Zimbabwe reported younger, single men similarly feared their potential for future marriage would be comprised by testing positive for HIV, resulting in men avoiding HIV testing altogether [32, 34–37]. In two studies with men living with HIV in Malawi and South Africa, men expressed concern that as a consequence of not being able to find or keep a spouse, they would also lose the opportunity to become a father, which influenced them to delay HIV testing [34, 35].…”

“…Men’s belief that the clinic was a place for women was found to contribute to a reluctance to seek an HIV test in four studies [29, 34, 36, 40]. Studies comparing men and women’s experience in accessing testing in South Africa and Lesotho attributed this perception in part to women’s greater opportunity for contact with health and HIV services, particularly their increased access to HIV testing through antenatal care [29, 40].…”

“…Consequently, the perception that HIV testing was for women was common, and South African men reported feeling excluded from and not welcome in clinics offering testing, deeming testing a “woman’s domain” [40]. In another study in rural South Africa, some men reported the preference for traditional healers, which were viewed as more male-friendly than clinics [34]. …”

“…The fear that HIV would compromise men’s ability to work and provide for their family resulted in the avoidance of HIV testing in three studies [29, 34, 36]. For men in Lesotho, this assumption was tied to the belief that HIV was a “death sentence” and being ill would make men “useless” in fulfilling their gender roles [29].…”

“…For men in Lesotho, this assumption was tied to the belief that HIV was a “death sentence” and being ill would make men “useless” in fulfilling their gender roles [29]. Zissette et al reported that men living with HIV in a peri-urban district of South Africa had delayed testing, and consequently treatment, for as long as they were physically well enough to work and carry out their role of provider [34]. In contrast, one study in Ugandan mining communities identified men’s role as provider as a facilitator to care [31]; men reported wanting to “test and live a few more years,” knowing an HIV test was the entry point to life-saving treatment, in order to gain more time to raise their children [31].…”