Over the last decade it has become increasingly clear that men and boys in all their diversity are missing in large numbers from HIV prevention and treatment services. In many countries, men and boys are less likely to test for HIV, less likely to initiate antiretroviral therapy, less likely to remain engaged in care, less likely to be virally suppressed, and as a result are dying at disproportionately higher rates than their female counterparts.
For the global AIDS response to be effective, greater attention must be paid to addressing the crisis of men and boys’ HIV outcomes. Since 2009 a growing number of studies have raised the alarm about men and boys’ low involvement in HIV services and urged action on two fronts:
The norms about manhood that encourage men to view health seeking behaviours as a sign of weakness and increased risk taking behaviour need to be challenged.
A significant body of research now provides a solid understanding of what programmes and policies are needed to transform gender norms and relations, including what sorts of interventions are effective at increasing men’s support for gender equality and reducing the likelihood that men acquire or transmit HIV. To effectively address women and girls vulnerabilities to HIV, and to improve men’s HIV-related outcomes, we must implement far more ambitious interventions aimed at advancing gender equality and improving men’s access to HIV services.
HIV is primarily transmitted via sexual intercourse, and particularly in Eastern and Southern Africa, the regional focus of this review, it is by and large a heterosexually-driven epidemic. It is well understood that to effectively address a sexually transmitted infection both partners must be treated. As such, it is imperative to understand and address the relational dynamics of mitigating risk for HIV between partners.
Additionally, it is critical to reach key populations and other high-risk individuals facing multiple layers of marginalisation and discriminatory laws and policies, who may not access health services as frequently as others, such as people who inject drugs, incarcerated populations, men who have sex with men, women who are not currently pregnant or breastfeeding, and adolescents and young people.
Health-system challenges contribute significantly to men’s low levels of uptake for HIV-related services. Whilst some barriers are the product of prevailing gender norms – such as men viewing clinical settings as female spaces, dominated by women and children, and female nurses – only focusing on gender norms is an oversimplification. Men lack the universal entry points to health systems that women generally have, which is compounded by a lack of extended opening hours and facility-based healthcare which hinders access to men who work outside their communities during the day.
Health-system obstacles go beyond the service delivery level and a broader, more supportive enabling environment needs to be intentionally created, including laws, policies and health strategies. In most countries, men are largely missing from public health strategies and there is therefore little mention of strategies or activities to improve their access to HIV services and other health services. Similarly, national health indicators tend to focus narrowly on women and children’s health while disregarding men’s use of services and their subsequent health outcomes. As a result, researchers are increasingly highlighting the so-called global gender gap in health-care access and health outcomes for men as a worrying blind spot in global health research, policy and practice.
In the era of the Sustainable Development Goals, it is recognized that HIV does not operate in a silo. As part of universal health coverage, HIV policies, programmes and services need to be integrated into existing primary health services, systems and budgets. In order to succeed in the fight to end the HIV epidemic by ‘getting to zero’, strategies are needed that target all of the actors engaged in this broader field of gendered power and inequality. This means, unequivocally, that men and boys must be engaged.