What makes a man?
As simple as the question may be, its varied, complex answers are the keys to effective HIV prevention throughout the world.
Worldwide, women bear the greatest burdens of AIDS. They are physiologically more vulnerable to HIV. There are more HIV-infected women than men. And women typically provide the most care to others who are sick with AIDS-related illnesses.
But it is men who drive the HIV/AIDS epidemic. Whether they are infected via sex or drug use -- the most common ways men are infected -- men are the vehicles through which HIV is transmitted to both men and women.
Even the best prevention campaigns targeting women are rendered ineffective when male partners refuse to change their risk behaviors or use condoms. More often than not, men's behaviors and refusal to change are rooted in their own beliefs and society's expectations about what it means to be a man.
In Asia, for example, there is "the basic double standard between men and women," said Pratin Dhamarak, regional program manager of the Family Health International (FHI) Asia Regional Office in Bangkok, Thailand. "Men are supposed to be experienced and know what to do in regard to sex," she explained, "while women are supposed to be innocent and submissive."
In other cultures, too, there are long-held ideas about what being a man means that contribute to the spread of HIV by, for example, viewing condoms as "unmanly." Women are often unable to protect themselves against HIV because their culture tells them they must comply with a man's wishes.
And HIV continues to spread. The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that 4.7 million adults throughout the world became infected with HIV in 1999, with new infections almost equally divided between men (2.4 million) and women (2.3 million). Of the 33 million adults believed to be living with HIV or AIDS, 17.3 million are men.
Men Make a Difference
In recognition of the role men play in virtually every case of sexual transmission of HIV, FHI supports many prevention projects around the world that specifically target men.
The work of these projects will be in the spotlight on December 1 -- World AIDS Day 2000 -- because this year's theme is "Men Make a Difference." It is also the theme of a two-year campaign, launched by UNAIDS in March 2000, focusing on the role of men in the HIV/AIDS epidemic. The campaign's objectives include motivating men and women to talk openly about sex, drug use and HIV/AIDS and encouraging men to take care of themselves, their partners and their families.
Programs aimed at men seek to build connections with men in places where they come together for work or to socialize with one another. Often men who travel or are separated from their families or communities for extended periods gather in border or port cities where there are ample opportunities to contract or spread HIV -- and to carry it home. For this reason, a number of FHI-supported prevention projects focus on these "mobile men," such as truck drivers, policemen, fishermen, taxi drivers and migrant workers.
A "Condom Tunnel" in Vietnam
A full day's travel by air and car from Hanoi is Can Tho. Traffic -- mainly motorbikes -- moves slowly along a stretch of highway lined by small brothels. In an initiative dubbed "the condom tunnel" by FHI's Implementing AIDS Prevention and Care (IMPACT) program in Vietnam, a series of billboards and banners with condom use messages will be placed strategically along both sides of the two kilometers of highway at this "hot spot."
"Once the client hops off the motorbike and parks it, he will be faced with more posters or possibly a leaflet from the parking attendant," explained Donna Flanagan, FHI's resident advisor in Vietnam. "Inside the bar-restaurant-brothels, the men find similar messages on the beer mats, wall posters and over the sound system." Besides the condom messages, teams of dramatists will offer comedy skits about subjects such as the challenges of men, women, sex and condoms.
The condom tunnel and street dramas are only two components of an overall men's campaign under the IMPACT program in Vietnam, which is funded by the United States Agency for International Development (USAID). Peer education in factories is another component. Then there are the six contests for such titles as "Mr. Great Farmer," "Mr. Great University Student" and "Mr. Great Civil Servant."
The idea is a bit like a beauty pageant, explains Flanagan, "in which the guys will be judged on a number of things -- one of which is their knowledge of and concern about their own health and that of their family." There will be "a lot of TV exposure for the winners," she added.
The men's campaign was designed to complement an IMPACT project that includes a new women's health club for sex workers in Can Tho. "No matter how we strive to help women develop self-esteem and sexual negotiation skills, they are nevertheless the weaker, non-paying partners in commercial sex," Flanagan said. "Putting the entire burden of condom negotiation on them is just adding one more chore to their already difficult lives."
Cambodian Seafarers in Thailand
In Rayong, a port city on the east coast of Thailand, some 40,000 Cambodian seafarers work in the fishing industry -- despite the government's official quota of 3,500 foreign workers for the industry. More than 90 percent of the Cambodians working in the port are illegal immigrants who pay up to $US 90 to agents who recruit them from their villages.
Men with limited education and without documents such as passports and visas can often find jobs as fishermen. The adventure attracts young men, but the work is hard and full of physical risks. For these reasons, Dhamarak says, "when fishermen get paid, they want to have a good time, spending money on drinks and sex."
Of course alcohol and condom use are often incompatible. But also undermining efforts to prevent these fishermen from contracting or spreading HIV is a low sense of self-worth. "Some men say their life is full of risk anyway," Dhamarak explained. "They don't know when they are going to die or get thrown overboard -- so why be afraid of AIDS?"
Preliminary focus group discussions with Cambodian seafarers revealed the men's limited knowledge of HIV/AIDS. About 60 percent of the participants reported engaging in commercial sex. Although most of them said they did not use condoms, they did not perceive themselves to be at risk for sexually transmitted infections (STIs), including HIV.
Limited access to condoms is also a problem. Language barriers make it difficult to buy condoms, and the "freelance" sex workers these men frequent (as opposed to those who work out of brothels) often do not carry condoms.
Prey Veng Province, with nearly 1 million residents and among Cambodia's most impoverished regions, is one of the "source communities" from which migrant Cambodian seafarers working in Thailand originate. A 1998 survey of sex workers in Prey Veng found an HIV prevalence rate of 34 percent -- the second highest in the country -- among "indirect" sex workers (who work in entertainment establishments or as beer promoters) and 29 percent among "direct," usually brothel-based, sex workers.
A new FHI project funded by USAID's Asia Near East Bureau is providing simultaneous cross-border HIV/AIDS interventions for Cambodian seafarers in Rayong and their families in Prey Veng. In Cambodia, a team operating under the Provincial AIDS Committee of Prey Veng will identify specific villages and families of seafarers working in Rayong. They will offer reproductive health education and HIV/AIDS counseling to families of migrants in the source communities. For those already ill with AIDS, home care services will be organized to strengthen existing health resources in the community.
In Rayong, mixed Thai-Cambodian teams will conduct outreach education, working within social networks and with government and private STI and health clinics to offer or expand their services to the target population. They will also make sure condoms are available around the areas where sexual contacts often take place.
The project will test innovative interventions that address the whole context and lifestyle of migrant seafarers. For example, because many fishermen cannot send money home and have no safe place to keep it, they are more likely to spend their earnings on alcohol and sex. "We try to help them maximize the benefits of their earnings and increase the communication and contact with families," Dhamarak said.
FHI also plans to provide "predeparture" information to fishermen, who often have unrealistic expectations about the working conditions they will face and the money they can make as undocumented migrant workers.
Ghana Police Service
Time away from home and a stressful job also put members of the uniformed services at high risk of HIV. The USAID-funded IMPACT Project is working with the military in Cambodia, Ghana and Nigeria and with the Ghana Police Service to support prevention efforts among these men.
Two years ago, with technical and financial assistance from IMPACT's program in Ghana, the country's national police force began a program aimed at preventing HIV among the police. Lectures on STIs, including HIV, are incorporated into the training curriculum used with police recruits. According to Dr. Godfried Asiamah, a chief superintendent and manager of the Ghana Police Service AIDS Control Programme, "these lectures emphasize safer sexual behavior in order to prevent sexually transmitted diseases, HIV and AIDS, and promote healthy living."
One obstacle the police training program has encountered is police wives questioning the usefulness of condom promotion. "They will ask, 'Are you not promoting promiscuity among our husbands by promoting and providing them with condoms when they go on operations outside their homes?'" Dr. Asiamah reported.
"Police are aware that the duties away from home, night patrols, a high rate of casual sex, unprotected sex, multiple sexual partnership and high alcohol intake common with the police are risky behaviors," Dr. Asiamah said. Nevertheless, he adds, police service members' perception of their own risk of HIV is low.
The Ghana Police Service's AIDS Control Programme is targeting about 20,000 policemen, as well as 80,000 of their dependents, including wives, for HIV prevention education and services. To date, 65 peer educators have been trained in three out of Ghana's ten police regions. The program plans to provide every police station and barracks in Ghana with at least one peer educator within the next five years.
Dr. Asiamah believes that peer education works "because peer educators are in continuous dialogue with their colleagues." Such dialogue is necessary, he adds, even though a 1999 survey showed that knowledge of STIs and HIV/AIDS was almost universal among the police. "This knowledge is not committed, as condom use was found to be low and other unsafe sexual practices were common among the police," Dr. Asiamah explained.
Besides education, peer educators offer condoms for sale to the policemen. Experience has shown that condoms distributed freely may not be used. "Policemen attach more importance to condoms if they are acquired with their own money," Dr. Asiamah observed.
The Risks of Secrecy
Whether for pleasure, economic reasons, compulsion or a lack of available women, many men have sex with one another despite often-harsh taboos against homosexual behavior in their societies. Surveys suggest that as many as eight in ten men who have sex with men practice anal sex. Unprotected anal intercourse -- whether between men or men and women -- has the highest level of risk for HIV transmission.
In countries where homosexuality is not accepted, men often hide their sexual orientation by having clandestine encounters or even ongoing relationships with other men. In these sometimes hurried circumstances, condoms are not likely to be used. Some men, married to women because of social or family expectations, have sex with other men "on the side."
All-male settings such as the military and prisons tend to increase sexual contact between men. Outside these settings, however, most of these men are likely to have sex with women -- increasing the risk of spreading HIV and other STIs to female partners outside the institutions.
Men who have sex with men -- whether exclusively or only occasionally -- are at heightened risk of contracting HIV and transmitting the virus. Both for the men's protection and to protect female partners -- and, by extension, offspring -- HIV prevention targeting men who have sex with other men is essential.
Hostility toward homosexuality has resulted in inadequate HIV prevention efforts in many countries. Some governments have refused to acknowledge that sex between men takes place. Others criminalize anal sex. Many governments refuse to support prevention efforts for men who have sex with men.
As a result, little is known in most non-industrialized countries about the extent of HIV/AIDS among men who have sex with men, the behaviors that put them at risk, or the kinds of HIV prevention services they need. Recent studies sponsored by FHI in Bangladesh, Cambodia, India and Nepal yielded some answers to these questions that are being used to design HIV/AIDS interventions for men who have sex with men in those countries.
Community Building in Bangladesh
The same-sex scene among men in Bangladesh is "distinctive," says Dr. Carol Jenkins, who was recently an FHI advisor there. In the fundamentalist Islamic area of Sylhet, for example, traditions tacitly permit older men to have sex with younger men because it contributes to the maintenance of female purity.
However, as Dr. Jenkins puts it, "the acceptability is in private -- publicly it is deplored." She noted that a random sample of rickshaw pullers this year in Chittagong, another conservative city in Bangladesh, revealed that 60 percent of the men had engaged in sex with other men in the last year.
Faced with this double standard of private tolerance and public condemnation, FHI is supporting the Bandhu Welfare Society, a local organization that has developed an effective, discreet strategy for reaching men who have sex with men in Bangladesh. "As being a man who has sex with men is a serious source of shame to men if their families find out," Dr. Jenkins said, "bringing these men together and giving them a safe space in which to discuss their sexual health issues has been extremely valuable and successful."
Youth Are Most Vulnerable
Expectations for how a man "should" behave can take on exaggerated importance for younger men concerned about "measuring up."
Young men in developing countries typically have more sexual partners than older men. They are more likely to inject drugs. But they do not usually see themselves as being at risk for HIV.
The disconnect between young men's behavior and perception of their own risk is apparent in Zambia, for example. There, 64 percent of young men ages 15 to 24 thought they had no risk at all of HIV infection -- even though having unprotected sex with multiple partners is relatively common among this age group.
The cultural power differentials between men and women frequently play out between young men and their female partners. These relationships can be exploitative or may involve money or gifts in exchange for sex. They can even be violent. In Southern Africa -- South Africa in particular -- young men frequently subject their partners to rape and other violence.
Boys and young men in some areas are less likely to know about HIV/AIDS than older men, despite their greater risk. One study of adolescents in Pakistan, for example, found that 25 percent did not know how HIV is spread. Surveys of young men in southern Africa also find them less likely to access medical treatment for STIs.
On the positive side, young men are open to influence, as Martin Foreman notes in a Panos Institute media briefing on men and HIV/AIDS.1 "Catching these boys and young men while they are still learning about their bodies and responsibilities to others makes more sense than trying to counter habitual attitudes and patterns of behavior in older adults," Foreman writes.
Opening the Dialogue
Jamaican boys are "under a lot of pressure to prove they're a man," says Hally Mahler, an FHI health communication and training officer. "I have some young Jamaican friends who tell me that in high school, boys race their friends to see how many girls they can sleep with. In a year they'll sleep with 40 to 50 girls. It's a manhood ritual."
To educate boys in Jamaica about sexuality and disease prevention requires addressing issues of power and even violence between men and women, Mahler explains. "Girls have little power in Jamaica in negotiating sex, like everywhere else," she said. "Boys are pressured to go out and sow their seed, prove they're not a sissy."
In Rwanda, Mahler has been assisting a youth group associated with the Catholic Church, Jeunesse Ouvrières Chrétienne, through an IMPACT project that focuses on behavior change. As elsewhere, bringing about changes in behavior requires first changing deeply held attitudes and beliefs.
In Rwanda, a girl is not allowed to consent to sexual relationships. "Even if she wants to have sex," Mahler explained, "she has to say no -- and to resist physically."
This means that even sex that might otherwise be consensual plays out as rape. "The sexual power is so skewed," Mahler said. "It's not that boys want to rape girls, but that's the sexual dialogue, and boys feel they have no way around it."
Mahler used a metaphor to help members of the Rwandan youth group challenge some of these assumptions. She asked for a gift, then repeatedly refused it as a colleague continued to press it on her. Finally, as he grew more insistent, she reluctantly accepted the small, gift-wrapped box. This led, somewhat haltingly at first, to a discussion about sending mixed messages with one's body and one's words.
In Jamaica, the same message is addressed more directly. In an exercise that has proved particularly effective, boys and girls exchange gender roles for a day, then talk about the experience.
"In Jamaica we've been doing this gender exchange for some time, and you really see it makes a difference -- kids start to respect each other more," Mahler said. "They find that boys and girls really want the same things in terms of respect and communication."
Such realizations are a small step toward an essential shift in the balance of power between men and women. Without strong expectations within their cultures that they will respect themselves and their sex partners (both female and male), men are unlikely to heed messages about condom use and safer sex.
As Mahler points out, "Until you can create an opening in the sexual dialogue, there's no place to start talking about prevention effectively."
Put another way, until men and women alike accept that part of being a man means protecting oneself and one's sexual partners against a deadly virus, HIV will continue to spread.
-- John-Manuel Andriote (April 2003)
John-Manuel Andriote is a freelance writer based in Washington, DC, and author of Victory Deferred: How AIDS Changed Gay Life in America.
References
- Panos Institute. AIDS and Men -- Old Problem, New Angle. Media briefing no. 6, December 1998.
