by Siyabonga Gema – HST Communications Officer and Sanele Mvelase – Cross-site Facilitator: Health Promotion Specialist
South Africa has the largest national Human Immunodeficiency Virus (HIV) epidemic globally, with an estimated 7.9 million persons living with the disease. New HIV infections among adolescent girls and young women are substantially higher than among males of the same age because of many factors, including gender inequality.
The impact of HIV on women and young girls has received much attention, resulting in the implementation of several programmes aimed at reducing the rate of new infections among these groups and fast-tracking their access to medical and social services. While these interventions are welcomed, there is still a major gap when it comes to responding to HIV service needs for men and young boys.
In South Africa, there are an estimated 2.46 million (2.36 million–2.56 million) adult men (15 years of age and older) living with HIV; this represents 37% of all adults living with HIV. Further to this, 78% of HIV-positive men know that they are living with HIV, versus 89% of women. Sixty-seven per cent of HIV-positive men who have been diagnosed are on treatment, compared with 72% of women.
There is clearly a need for a focused and strategic approach in addressing the issue of men's access to HIV care and treatment services, and tackling the major contributing factor of HIV stigma among men. The Health Systems Trust's (HST's) Cross-site Facilitator: Health Promotion, Sanele Mvelase, gives us a better understanding of HIV stigma and its impact on men.
What, in your view, is the biggest enabler of HIV stigma among men?
We need to understand that stigma is entrenched in fear of HIV, leading back to when it was discovered and the many lives it took when little was known about the virus and no antiretroviral therapy was available. Even today, with South Africa having the largest HIV treatment programme in the world and so much knowledge being accessible across the globe, it does not seem like enough, because there are men who still believe that HIV is a killer disease.
In my opinion, internal stigma among men living with HIV has been the greatest driver. Suppose I am a man living with HIV and aware of my HIV status. As much as men can sit and talk about sex, it is not so easy to talk about living with HIV, because of the fear of being judged or the misconceptions that arise after you have disclosed. Internal stigma can be so severe that, as a man, you may find it difficult to consult medical staff about it, purely because of toxic masculinity and the fear of being seen as vulnerable or weak.
With that being said, it is one thing to inform and educate people about something, but the levels of comprehension among different people are not the same. Practicality is what is really needed. Information can never be enough. When a man living with HIV takes his pills in front of his peers and friends, he opens a door of opportunity for them to learn about what it truly means to live with HIV. When they see that he takes his treatment daily and is able to continue living well and healthily, it shows them that it is doable.
Where is the discourse on providing adequate healthcare for HIV-positive men?
When knowing one's HIV-positive status results in social isolation, a man's emotional and mental well-being could be affected, especially if he does not get counselling. This goes back to masculinity: masculinity that surpasses gender roles or societal norms. As family providers, men are reluctant to take time to visit a clinic, and because men are physically stronger, they tend to believe that they can fight anything, and this prevents them from seeking medical attention. The number of men taking ARVs will grow at a slower pace, as they are hesitant to visit health facilities and prefer to seek help later ‒ unfortunately, when they are really ill and have possibly transmitted the virus to their partners. Health organisations and government departments may provide easy access to public health services, but if men constantly resist help, it is a huge battle to overcome.
What role do you think cultural gender roles play in this situation?
If we look at HIV and gender in a broader sense, we learn that culture will favour men. In patriarchal societies, a woman cannot negotiate safe sex practices, which makes her vulnerable to HIV infection from her intimate male partner ‒ and because he is backed by culture, this becomes a norm. One way in which culture can help in this, especially in rural communities where kings rule, is if the monarchy steps in; the king and his male advisors can join forces with health institutions to educate and have conversations with younger and older men about the importance of safe sex and how they can protect themselves and their partners.
What have been some positive gains in the treatment of HIV among men?
Among the positive gains are men who disclose their HIV-positive status in public; doing this has assisted others in taking ownership and living a healthy lifestyle. The U=U concept (Undetectable = Untransmittable) has also been very beneficial in encouraging men to enrol for and adhere to HIV treatment. The thought of being intimate with someone with no fear of infecting your partner is very heartening for men, as it aligns with their concept of and ability to fulfil the male gender role.
What avenues of support are there for HIV-positive men?
Peer support for men living with HIV is available, for example, through the Coach Mpilo and MINA for Men for Health programmes which not only support men at our facilities, but extend help on social media platforms like Facebook. The most special aspect about this is having men living with HIV sharing their own personal journey to a positive and healthy life. This not only motivates other men who are HIV-positive, but also assists in mobilising more men to test for HIV and to know their HIV status.
Is HST doing any work to address this?
Yes. Collaborating with other relevant stakeholders and in support to the Department of Health (DoH), we have done some great work, for instance our support with the implementation of programmes like Coach Mpilo and the MINA campaign, both in facilities and at community level during Izibaya zamadoda and Ikhosomba lamajita. Before such programmes, HST supported the DoH in using the quality improvement approach for service provision to men living with HIV, thus improving the country's HIV care and treatment cascade for men. HST also supports specific men-friendly services, with dedicated Mobile Clinics, Men's Corners in facilities and men-only streams in selected facilities. In addition, HST is part of the Men's Forum at both provincial and national level, guiding and supporting policy development.
Is there light at the end of the tunnel?
There is definitely light at the end of the tunnel: the number of HIV-infected men is still a concern, but for those who are living with HIV and on medication, we can say there is improvement. More must be done, though. It takes only one person to stand up and show what's possible, and the rest will gradually follow. One person at a time, a group of people, a community, then a nation at large. We all need to sing the same tune ‒ that living with HIV is not a death sentence and that with some adjustments, life continues normally if you're on treatment and virally suppressed. The Sixth South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM VI) results show that men are living longer, the HIV prevalence rate is lower among men, and the infection rate has reduced in the last three years. These are positive outcomes directly related to increased treatment accessibility and adherence support.
Men and members of the public seeking information and support can contact any of these organisations:
MINA For Men For Health: https://www.minaformenforhealth.co.za/
Coach Mpilo: https://www.coachmpilo.co.za/
South African National AIDS Helpline: 0800 012 322