“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”
MEN AND THE HIV EPIDEMIC
Rivers and Peter Aggleton
Thomas Coram Research Unit
Institute of Education, University of London, 1999
As the epidemics of HIV
and AIDS have developed over time, international organisations, national
authorities and non-governmental organisations (NGOs) have recognised that
social inequalities and power relations have an important impact on HIV
transmission. Factors such as poverty, migration and urbanisation have a key
role to play in facilitating HIV infection (Sweat and Denison, 1995). Other
variables known to influence the vulnerability of individuals and groups
include social background, age, race, gender and sexuality. Not
infrequently, these different variables interact with one another so as to
render some groups systematically more vulnerable and other groups more
protected (Piot and Aggleton, 1998).
Importantly, and for the
purposes of this review, there has been increasing awareness that prevailing
relationships within and between the sexes, or gender relations as they are
more usually called, affect not only the development of the epidemic (Carovano,
1992), but the manner in which individuals, groups and communities respond
(see, for example, Aggleton and Warwick, 1998). As used here, the term
gender refers to the social shaping of femininities and masculinities, and
challenges the idea that relations within and between the sexes are ordained
by biology or nature (Ankrah and Attika, 1997). Unequal gender relations can
be seen in many ways but are particularly visible in the special
vulnerability of women to HIV and AIDS in developing countries, and in men's
risk taking behaviours. Economic and social vulnerability, as well as
stereotypical gender roles, influence women's and men's vulnerability to HIV
infection, while fuelling the overall course of the epidemic. As Meursing
and Sibindi (1995: 66) have recently written 'the AIDS epidemic thrives on
rigid sex-role definitions.'
Recent reviews also
suggest that women in many parts of the developing world are less likely to
control how, when and where sex takes place, thereby increasing the
likelihood of unwanted pregnancy, STDs and HIV (see, for example,
International Center for Research on Women, 1996). Women's vulnerability to
HIV infection is enhanced for several reasons including their economic
dependence on men, lack of access to education, poverty, sexual
exploitation, coercion and rape, as well as by the fact that women are more
likely than men to sell sex in order to survive (Aggleton and Rivers, 1999).
Surrounding and to some extent legitimating these inequalities are
ideologies of masculinity and femininity which make it seem 'natural' that
men should have the upper hand when it comes to economic decision making,
opportunities for advancement, expressing their sexual desires and
satisfying their sexual needs.
While traditional gender
roles render women less able to control the nature and timing of sexual
activity, men are more able to determine how, when and with whom sex takes
place. Despite this, dominant ideologies of masculinity (which emphasise
male sexual pleasure, value the display of sexual prowess and encourage men
to have multiple sexual partners) place men and their partners at heightened
risk of HIV and AIDS. While women may be prepared to take measures to
protect themselves from HIV infection, and while men may have some
investment in protecting themselves, their partners and families, women's
desire for safer sex not infrequently runs 'into a wall of un-cooperation
from men' (Meursing and Sibindi, 1995). In this paper we will examine what
it is about gender relations and dynamics, and dominant versions of
masculinity in particular, that enhances risk and hinders men from
protecting themselves and their partners from HIV infection. Men's
relationships with women and with other men will be examined, and the
importance of involving men more fully in programmes for improved sexual
health and greater gender equality will be stressed.
Before doing this,
however, it is important to stress that the dangers of working from a
stereotypical description of 'men' and their desires, motivations and
interests. There is enormous variability between individuals, not only
between societies but within them. While some men display little interest in
protecting themselves and their partners against disease, perhaps believing
themselves to be 'invincible', others behave with the utmost responsibility
and consideration for others. Moreover, while perhaps the majority of men
prefer to have sex with women, a not insubstantial number of men have sex
with members of both sexes or with other men alone. Whether the individuals
concerned understand this behaviour to be 'heterosexual', 'bisexual' or
'homosexual' varies considerably, since in perhaps the majority of countries
these terms only enjoy currency in the scientific, medical and
epidemiological literatures, and rarely form part of the local vernaculars
within which sex is talked about and understood. Analysing the position of
'men' in relation to the HIV epidemic is therefore a complex and difficult
task, and one which cannot adequately be accomplished within the confines of
a review such as this. We are aware, therefore, that we will probably raise
as many questions as offer answers, yet hope that our analysis of men and
masculinities in relation to the epidemic offers some useful leads for
future programme development.
II. GENDER AND
THE HIV EPIDEMIC
Policies and programmes
to promote greater equality between men and women are considered to be
crucial to HIV prevention (see, for example, Rao Gupta, 1995; d'Cruz-Grote,
1996). Despite increasing recognition of the importance of more equal gender
relations, many programmes continue to work solely with women in an attempt
to help empower them in sexual relationships. As Wood and Jewkes (1997)
point out, however, this focus is often based on an erroneous set of
assumptions about women's ability to control and sustain their sexual
health. Only rarely do women have direct control over the contexts,
occasions and forms within which sex takes place, and there is a substantial
literature to indicate how difficult it is for women to persuade men to use
condoms and/or reduce the number of partners in circumstances where the
latter are unwilling to do so (see, for example, World Health Organisation,
1994). In the field of international development, and while several
programmes have recently altered their terminology from 'women in
development' to 'gender and development', perhaps the majority of
initiatives to challenge and transform prevailing gender relations still
focus on women alone. Relatively few start from a recognition of the needs
of both women and men (White, 1997).
This over-emphasis on
reaching women who are particularly vulnerable to HIV infection has led to a
neglect of two key factors: men's participation in programmes and
programming and broader social circumstances (Mbizvo and Bassett, 1996). For
example, while numerous HIV prevention programmes and interventions have
focused on women sex workers, considerably less attention has been given to
their male clients. Even today, men are rarely written about in the
literature on development and, where accounts do exist, men usually appear
as background figures and are rarely centre stage within the analysis. By
way of contrast, in much of the literature on gender and development, women
are written about as hard working and caring with a strong orientation
towards community, while men are constructed as individualists who put their
own desires first. The overtones here of 'colonial stereotypes about 'lazy
natives' are uncomfortable, to say the least' (White, 1997: 16). Indeed, men
in developing countries have almost uniformly been characterised as
inconsiderate, unreliable, predisposed to coercion, rape and violence, as
well as being relatively unable to control or change their behaviour. As
such, they offer a counterpart for images of women as disempowered and with
little control over their social and sexual lives. A more complex situation
does in fact pertain (Sweetman, 1997).
While some commentators
have called for increased male participation in work towards greater gender
equality and improved sexual and reproductive health, concern has also been
expressed about shifting the focus, and resources, from women to men. Berer
(1996: 7), for example, has suggested written that '...just as women's
specific problems are finally getting some attention on the world stage ...
it seems that focusing only on women is no longer acceptable.'. For Berer
and other writers, the key may lie in involving men in ways which are more
supportive of both women and women's concerns: 'If empowering women is to
remain the end point ... policies for change that involve men must also be
grounded in a woman-centered and gender-sensitive perspective, not just
taking men's perspectives or needs into account.' (ibid: 9).
Inequalities and Masculinity
Gender differences, and
the inequalities associated with them, can be explained in a variety of
ways. However, while it is widely accepted that gender roles are not
'natural' but are culturally produced (Hearn, 1987), there is no consensus
as to what causes them to emerge in the first place, or what leads them to
change over time. Still less have the links between gender roles and broader
sexual inequalities been fully explained. This poses major problems for any
effort to explain the 'position' of men in relation to the sex and sexual
matters, or the ways in which masculinities 'as sets of ideologies governing
thoughts, actions and behaviours ' are constituted and reproduced over time.
Yet some understanding of these phenomena is important if we are to develop
programmes to engender greater equality within and between the sexes, to
reduce HIV related risks, and to promote sexual and reproductive health more
Connell has recently
argued that research has failed to produce a 'coherent science of
masculinity' (Connell, 1995: 67). In his view, masculinity is not a static
and unchanging social norm, rather '[it]...is simultaneously a place in
gender relations, the practices through which men and women engage ... and
the effects of these practices' (Connell, 1995: 71). Multiple masculinities
influenced by class and race as well as gender clearly exist, and it is
important to examine not only gender relations between men and women, but
also gender relations between men in making sense of gender inequalities and
Notions of 'hegemonic
masculinity' help explain why certain versions of masculinity become the
most successful and powerful in particular environments. Men who do not meet
the 'standards' set by hegemonic masculinities, which in themselves can and
do change over time, are viewed as unsuccessful and powerless, since within
a society one or more forms of masculinity is likely to be 'culturally
exalted'. Although not all men conform to the dominant versions of
masculinity that circulate at any one moment in time, those who do not often
find themselves discriminated against.
Despite this, all men
probably share in what Connell (1995: 82) has called the patriarchal
dividend through which men gain honour, prestige, the right to command, and
material advantage over women.
ideologies of masculinity, and their consequences for women and men's lives,
is not easy. Like hegemonic ideologies of all kinds, dominant beliefs about
what 'real' men are like (and by extension what women and children are like)
seek to incorporate all alternative images, accounts and explanations within
their sphere of influence. Thus, hegemonic masculinities legitimize not only
unequal roles and relationships between women and men, but also between men.
They encourage us to see men who do not live up to the ideals of hegemonic
masculinity as effeminate, weak, subservient or immature. And they seek to
deny men an active role in changing prevailing gender relations and
inequalities for the better (Cornwall, 1997).
and Sexual Health
relations have a serious impact on men's sexual health and the sexual health
of partners and families, in addition to shaping the broader oppression of
women. Estimates suggest that between 60-80 per cent of women currently
infected with HIV in sub-Saharan Africa have had only one sexual partner
(Adler et al, 1996). Research in many parts of the world suggests that men
have a greater lifetime number of sexual partners and that there are clear
double standards regarding the behaviour of men and women (de Bruyn et al,
1995; International Center for Research on Women, 1996). For example, while
in many cultures women are expected to preserve their virginity until
marriage, young men are encouraged to gain sexual experience (International
Center For Research on Women, 1996). Indeed, having had many sexual
relationships may make a man popular and important in the eyes of his peers
(Abdool Karim and Morar, 1995). Male sexuality is often thought of by both
men and women as unrestrained and unrestrainable, and in some parts of the
world having an STD is considered a badge of honour which confirms manhood
(de Bruyn et al, 1995). So, while lack of knowledge and sexual inexperience
remain highly valued for young women, men may be stigmatised if they cannot
demonstrate having had a wide sexual experience.
Research also suggests
that sexual decision-making is usually controlled by men. In many cultures,
coercive sex and sexual violence are not unusual (see, for example, de Bruyn
et al, 1995; Wood and Jewkes, 1997). According to both boys and girls
recently interviewed in Recife in Brazil, for example, girls and women are
often coerced into sex and some young women may obey their boyfriends'
wishes because they believe that girls are 'meant' to be compliant and
subservient (Vasconceles, Garcia and Mendonca, 1997). While there may be
differences in prevailing definitions of masculinity, greater freedom, power
and control characterise male sexuality across a wide spectrum of different
cultures. Furthermore, where women are most economically dependent on men,
their ability to make decisions about sex may be most constrained. This
reinforces the importance of economic development for enhanced levels of
gender equality (Rao Gupta, Weiss and Mane, 1996).
In order to avoid the
problems which come from failing to conform to dominant gender stereotypes,
women risk the damage associated with conformity (Overall, 1993). Men on the
other hand may find that by conforming to stereotypical versions of
masculinity, they place themselves and their partners at heightened risk.
These contradictions need to be exposed so as to identify the dividend that
accrues to both women and men when existing gender roles are transformed or
cease to be obeyed. By working to show how many men do not meet idealised
forms of masculinity, discussion about how some men are marginalised can
begin to take place. As Cornwall (1997: 12) has recently put it, 'If gender
is to be everybody's issue, then we need to find constructive ways of
working with men as well as with women to build confidence to do things
differently.' The intimacy, complexity and entrenched character of
prevailing gender relations and ideologies mean, however, that work of this
kind will need to be sustained over time (White, 1997). While women may be
the initiators of this kind of dialogue, their task will be 'impossible
unless a dynamic is generated amongst men to question their personal
practice' (ibid: 15-16). A first step in analysing men and masculinities,
therefore, may lie in examining men's 'private stories', and how these
accounts and experiences support or contradict the ideologies promulgated by
more hegemonic masculinities (White, 1997).
Long and Ankrah (1996)
have recently argued that sexual responsibility among men is central to the
health of both men and women (ibid: 392). In their eyes, funding priority
should be given to programmes and activities which aim to reach both men and
women, rather than women alone. Community mobilisation and other techniques
may be used to help increase awareness among men of how HIV/AIDS can affect
the lives of their daughters, wives, mothers, kin and friends. For Long and
Ankrah, women's empowerment cannot be achieved by women alone, but requires
the support of men for its successful realisation (Long and Ankrah, 1996:
Gender and Other
Cornwall (1997: 9) has
recently written that in much development work, gender analysis is used to
guide planners by 'delineat[ing] distinctions between men-in-general and
women-in-general'. Little is usually said about the intersection of gender
with 'other differences such as age, status and wealth' (ibid: 9). In
reality, gender relations and ideologies interact with other social
inequalities, including those based on class, sexuality, age, religion and
White (1997) has
recently described how some men in Bangladesh are exploited by other men
because of their ethnicity, and a clear interaction between gender,
ethnicity and class as determinants of sexual risk taking has also been
shown among mine workers in South Africa (Campbell, 1997). Here, as in other
countries, lack of employment opportunities close to home encourages men to
migrate. Working in highly dangerous conditions, and removed from the usual
sources of familial and social support, life in cramped conditions is both
stressful and lonely. Drinking and paying for sex too readily become
normative, heightening the HIV-related risks faced by the men and their
In contrast, women's
interests are often understood as relatively little influenced by social
class, and 'gender sensitive' development programmes which aim to make women
less poor are often conducted in isolation from work of other kinds. For
some writers. 'Gender [has become] the justice issue, women the minority
(... [and]) social development (...) at least in some agencies (...) very
largely commandeered by 'gender specialists'' (White, 1997: 21). A
broadening and deepening of our understanding of power and inequalities
seems called for if we are to better understand the sometimes complex
vulnerabilities linked to class, gender and ethnicity which structure women
and men's lives. While men clearly benefit from gender inequality (i.e.
through their greater access to schooling, economic advantage and power), we
might profitably focus on masculinity and its effects by examining the
institutions, cultures and practices that sustain both gender inequality and
other forms of domination, such as those attributable to class, religion and
race (White, 1997). As Cornwall (1997: 11) has put it, it is important to
remember that 'not all men (...) have power; and not all of those who have
power are men'.
Developing a more
sophisticated understanding of gender inequalities and their determinants
requires an examination of sexual divisions and ideologies beyond those that
operate to structure men's relationships with women. The importance of men's
relationships with one another has already been mentioned in relation to the
way in which men who do not conform to dominant ideologies come to be seen
as unmanly and effeminate. These social perceptions not infrequently link to
the homophobia and heterosexism that can be witnessed in almost every
society. They also fuel the existence of homosexual relationships and roles
modelled strongly on heterosexual lines, for example, the activo/passivo
relationships characteristic of men who have sex with men across much of
central and southern America and north Africa, and the emergence of strongly
gendered 'types' of male sex work that emerge in these same contexts (Aggleton,
Sex between men remains
highly stigmatised in many societies, and men who have sex with other men
(and who are open about this) not infrequently experience marginalisation,
stigmatisation and severe social sanctions (McKenna, 1996). In perhaps the
majority of countries, homosexual masculinities lie at the bottom of the
gender hierarchy among men, and overt expressions of 'gayness', for example,
are often equated with femininity (Connell, 1995). While it is less useful
to talk about specifically gay identities outside the West and its spheres
of socio-sexual influence, men who have sex with men and who do not
subscribe to dominant versions of masculinity are clearly discriminated
against in the majority of societies worldwide.
Interestingly, in some
cultural contexts it is not sex between men per se which generates
disapproval, but rather the behaviour of those men who show attributes which
are traditionally associated with women. It is important, therefore, to
examine sexual identities from a culturally sensitive local standpoint
rather than through Western frameworks and understandings. Khan (1997) for
example, has recently written about sex between men in India and Bangladesh,
both countries in which social identity is much influenced by familial
relations. Here, men who have sex with other men may not be penalised so
long as their activities remain hidden. In this kind of context, hegemonic
masculinity seems threatened less by sexual preference and habit than by the
refusal to enter into contractual and reproductive relations with women.
Similar findings have been reported from research conducted in Islamic
societies including Pakistan (Murray and Roscoe, 1997)
Generational issues are
also important determinants of sexual inequalities and discrimination. Young
people often have less access to information and services than older people,
have less economic power and are at heightened risk of sexual exploitation (Aggleton
and Rivers, 1999). Recent research in Tanzania (Seel, 1996), in Zimbabwe (Runganga
and Aggleton, 1998) and many other countries suggests that young men may
attempt to redress inter-generational inequalities through sexual activity
with multiple partners, which is seen by them as symbolising adulthood and
Overall, analyses of
gender, sexuality and inequality need to take account of the manner in which
factors such as age, class, ethnicity and culture interact to determine the
form that gender and sexual divisions take. It should be clear from what has
been said so far that the most successful programmes and interventions are
likely to be those which move beyond a narrow focus on women's concerns and
needs (while recognising these as important) to look at the ways in which
contemporary masculinities and constructed and reproduced in particular
societies at a given moment in time. By understanding more about the
relationship between hegemonic masculinities and more subordinate forms, we
may be better placed to challenge the former and their divisive effects
(both for women and for men), so facilitating the transformation of social
relations within and between the sexes.
A number of researchers
and practitioners have recognised the importance of involving men in work
designed to prevent HIV infection, as well as to address the broader
inequalities which pose a threat to sexual health (Hadden, 1997; Wood and
Jewkes, 1997). One of the most important 'gaps' in work for improved sexual
health, however, is the absence of clear information about men's attitudes
toward sex and sexuality. We need to know much more about men's perspectives
and interests if we are to engage them productively in work for the
prevention of HIV infection and improved sexual health.
For example, many women
report that men refuse condom use, and may even become violent when safer
sex is requested. Women in Thailand, for example, report that condoms might
be seen as appropriate for 'casual sex', but not within the context of a
longer term relationship (Cash and Anasuchatkul, 1993). Other women have
reported that suggesting a partner use a condom may be tantamount to
accusing him of infidelity (Heise and Elias, 1995; Ankrah and Attika, 1997).
Interestingly though, we know very little about men's own perceptions on the
same issues and concerns.
Orubuloye et al (1997)
have argued that there has been a consistent failure to enquire into men's
belief systems in relation to sex and sexuality. Where researchers have
enquired into men's beliefs, findings have sometimes confounded commonly
held views about male attitudes with the opinions of respondents themselves.
For example, recent research conducted among South African men, suggests
that the timing of requests for condom use is important in mediating likely
responses. Against an overall background of reticence towards condom use,
men reported that if they were asked to use condoms prior to sexual arousal,
they were more likely to use them. However, they also acknowledged that if
asked to use a condom when they were highly sexually aroused, they might
become coercive and violent (Hadden, 1997).
Similarly, research has
provided new insight into the meanings of anal sex when it takes place
between men and women. In much of the development literature, heterosexual
anal sex is commonly assumed to be a method of preserving virginity and
preventing pregnancy. However, recent studies suggest that for some
Brazilian men at least, anal sex may also be symbolic of increased power and
control over women. For men interviewed, anal sex was seen as a 'conquest'
to be equated with 'taking' a woman's virginity for a second time
(Goldstein, 1994). Learning more about what sex means to men in different
contexts is therefore an important prerequisite for the design of more
effective programmes and interventions (Hadden, 1997).
Because women have less
control over sexual communication, a substantial number of programmes have
concentrated on work to empower girls and women. But, failures in helping
women to change sexual behaviour and bringing about more equal gender roles
demonstrate that boys and men too must be involved (Mbizvo and Bassett,
1996; Barnett, 1997). As Rao Gupta, Weiss and Mane (1996) have suggested, it
is essential '... that interventions to strengthen women's sexual
negotiation skills be conducted concurrently with educational programs
designed for boys and men. Such programs must go beyond teaching condom
skills by promoting men's participation as equal partners in safer sex
planning,' (ibid: 345).
Reaching men in the
manner advocated remains something of a challenge, however, because it
remains unclear what messages will appeal to men and what are the key
factors motivating safer sexual practices (Robinson, 1991). While only a
small number of programmes have been designed to involve men, even fewer
have attempted to systematically evaluate and report on the impact and
effects of the work undertaken. Our review of the available evidence is
therefore limited, and the programmes, projects and activities examined
often describe work undertaken with relatively small groups of men. We will
begin by reviewing work designed to increase condom use among men.
Subsequently, we will look at programmes and projects that have tried to
work with men considered to be at high risk of HIV infection, including
truckers, migrant workers, clients of sex workers and STD patients. Next,
some workplace based programmes will be described. Finally, some specific
initiatives and activities addressing issues of relevance to men who have
sex with men will be discussed.
Much of the HIV
prevention work so far undertaken with men has been designed to increase
condom use. Consistent condom use, one of the few effective strategies
available to prevent HIV transmission, seems however to be problematic for
men, and in consequence for women (Hulton and Falkingham, 1996). In Senegal,
as in a number of other countries, it has been reported that men may suspect
that a woman is a sex worker or has other lovers if she requests condom use
(Niang, Benga and Camara, 1997). Some men in this same context reported
believing that condoms could make men impotent (ibid). A programme aimed at
both men and women was designed to increase safer sex and condom use in
Senegal using traditional women's associations. The programme proved
relatively successful with women, especially in terms of increased levels of
knowledge, but the impact on men was much less pronounced. This was not
perhaps surprising given that women were the main channel of communication
in the programme. The authors conclude that more research is necessary in
order to understand how to effectively reach men (Niang, Benga and Camara,
Hulton and Falkingham
(1996) have collated survey data collected in the early 1990s in ten
countries including Pakistan, Egypt, Niger, Ghana and Kenya. Data from over
69,000 women and 18,130 men was available. Reported lifetime use of condoms
by men was significantly higher than that of women. Hulton and Falkingham
(1996) suggest that large differences in ever-use of condoms may be because
of past use by males with sexual partners before marriage and in
extra-marital relationships. In Zimbabwe, for example, of those men having
sex in the prior four weeks with a spouse, 12 per cent reported having used
a condom, while for those men who had sex with a non-spousal partner the
figure was 60 per cent (ibid).
Other research findings
support the finding that condoms are not consistently popular with men,
especially with their wives (Meursing and Sibindi, 1995). Amamoo (1996), for
example, writes that men may interpret requests for condom use as betrayal
or attempts to deprive them of their rights in sexual decision-making within
the relationship. Women in a diverse range of countries have reported being
unable to act upon what they know about HIV and AIDS for fear of implying
through condom use that a partner is not loved or trusted. Such requests
disturb the intimacy which is central to many relationships and can result
in violence, abandonment or rape (Ankrah and Attika, 1997).
Wilton's work (1997)
offers some interesting insights into the reasons why condom use may be so
unpopular among men. She suggests that masculinity itself is threatened by
condom use. There are several reasons for this: first, if condom use is
requested by a woman this allows women to define the terms of sexual
engagement; second, condom use may involve men having to deprioritise their
own sexual pleasure; third, for men to demonstrate a degree of control over
sexual behaviour may be feminising since male sexuality is most usually
understood as uncontrollable; and finally, risk-taking in itself is
considered to be typically masculine. Wilton (1997) points out that
non-penetrative sex is rarely an option in heterosexual relationships since
vaginal sex tends to be understood as adult sex, and other forms of sexual
pleasure may be seen as a kind of backsliding into adolescence. Her work is
important since it stresses the importance of working with men as well as
women to de-construct stereotypical gender roles if HIV transmission is to
Because of male
resistance to condom use and the difficulties which women may have in
negotiating the use of condoms, some authors have suggested that female
controlled protection is central to HIV prevention (see, for example, Heise
and Elias, 1995). The female condom, although more expensive and less widely
available, provides women with an extended choice of protection, and recent
research suggests that male resistance to the female condom may be less than
to the male condom (Aggleton, Rivers and Scott, 1998).
Hawkins (1996) has
observed that current programmes to meet women's immediate sexual and
reproductive health needs, including those designed to promote condom use,
may inadvertently reinforce and preserve inequalities in gender and
sexuality. Marketing strategies which attempt to encourage condoms to be
used often use stereotypical and 'macho' images which may further entrench
gender stereotypes and inequalities. Gupta (1995) recommends that efforts be
made to support the marketing of new and more egalitarian images of
masculinity and femininity. Messages which promote images of predatory males
and passive females may have brought about some short-term increases in
condom sales to men, but have done so only at the expense of reinforcing
damaging gender stereotypes.
Men at Special
Programmes aimed at
groups of men considered to be at special risk of HIV infection have taken
place in some developing countries. These groups include truck drivers, who
are highly mobile and may spend long periods of time away from home, migrant
workers who are separated from their families and communities, the clients
of sex workers, and STD patients.
Truck drivers in a range
of countries work under conditions which directly promote risk behaviour
through mobility, the time they spent away from families, and the use of sex
workers (Robinson, 1991; Madrigal, 1991). Evaluations of the effectiveness
of HIV prevention programmes with truckers in Africa and Asia offer
important insights into what can be achieved through this kind of work.
Raman (1992), for example, has recently described work recently undertaken
by the AIDS Research Foundation of India (ARFI) with sex-workers' clients,
including truck-drivers, in Madras. As part of this programme, condoms were
distributed at transit-stops and educational cassettes played. Peer opinion
leaders were also recruited to tell port and dock workers stories about men
who practise safer sex, and posters were put on display in barbers and wine
shops. Short street plays were performed and free STD services provided.
Informal monitoring of the project's activities suggested that sales of
condoms increased (Raman, 1992).
Elsewhere in India the
Bhoruka AIDS Prevention (BAC) Project has concentrated its work on the
trucking routes between Calcutta and Kathmandu which have been identified as
important sites of high-risk sexual behaviour (Amin, 1996). Among other
initiatives, the BAC Project has established a range of services including
STD testing, condom distribution and counselling at Raxaul, a major
intersection for trucks travelling between India and Nepal. Data collected
at regular intervals during the first year of the programme showed that the
number of men seeking counselling and HIV testing there increased from 136
to 2,431, and the number of condoms distributed upon request rose from 630
to 26,290 (Amin, 1996).
A linked programme of
interventions collectively called Avancemos ('Let's Move Ahead') organised
by NGOs in the Dominican Republic has disseminated messages to the regular
partners of sex workers, their clients and to other men involved in the sex
industry (AIDS Control and Prevention Project, 1997). A comic book was
developed and regular workshops held to encourage the proprietors of
brothels and other commercial sex establishments to support prevention
efforts. These sessions approached the epidemic from the perspective of the
owners and managers, and their desire to attract more customers. Impressed
with the quality of services, a number of enterprises have recently began to
pay small fees to support the work of Avancemos because they want the
activities to continue. Project workers have concluded that working with a
wide range of men involved in the commercial sex industry is essential for
effective prevention efforts (AIDS Control and Prevention Project, 1997).
A number of authors have
recognised that economic and social migration influences and facilitates the
spread of HIV. Campbell (1997) has noted that high levels of HIV infection
are characteristic of a range of unstable and economic disadvantaged social
settings in Southern Africa and has looked at the ways in which dangerous
and risky work may influence the attitudes of men towards sex. Forty two
migrant miners were interviewed in Johannesburg. Although all the
interviewees had been exposed to HIV-related information and had good levels
of knowledge about AIDS, knowledge did not translate into safer sexual
behaviour. Living and working conditions in the mines are highly dangerous
and stressful, and drinking and sex appeared to be two of the few diversions
easily available to the men. What is more, facing risks at work daily may
mean that men are less inclined to worry about the long-term risks of HIV
infection. For example, interviewees commented that 'the risk of HIV/AIDS
appeared minimal compared to the risks of death underground, and suggested
that this was the reason why many mine workers did not bother with condoms'
(ibid: 277). Interviewees were relatively fatalistic about the chance of
accidents at work and felt powerless to change their circumstances. Campbell
(1997: 277) writes that ' ... this sense of powerlessness is an important
feature of the contextual backdrop [and] is an important determinant of
health-related behaviour'. Importantly, masculinity emerged as a leading
narrative in interviewees accounts of their work, sexuality and health. The
miners took pride in working in dangerous conditions and responsibility for
providing for their distant families. Understandings of masculinity were
also reinforced by male peers with whom much time was spent socialising
outside the immediate work context. According to interviewees, men were
defined by their bravery, fearlessness and desire for sex. Somewhat
paradoxically, therefore, 'the very sense of masculinity that assists men in
their day-to-day survival also serves to heighten their exposure to the
risks of HIV infection' (ibid: 278). Campbell argues that her research
supports the claim that an important way of reducing levels of HIV infection
could be to alter the social and material conditions which facilitate and
reinforce risky sexual practices.
Thailand, interviews and focus groups have recently been undertaken with 936
men, including migrant workers involved in the harvesting of sugar-cane
(Maticka-Tyndale et al, 1997). The focus of this research was on men's
relationship with sex workers. High levels of knowledge about HIV infection
were reported, and of those who had paid for sexual services in the past
year, 76 per cent reported condom use. However, the researchers also found
that the context in which sex was sold had an important bearing on whether
or not condoms were used (Maticka-Tyndale et al, 1997). In part, this may be
because of the insistence on condom use by bar managers, but the researchers
found that men also perceived sex with women who were not working in
environments where sex was traditionally sold as less risky. When men paid
for sex at festivals, in markets or on the sugar plantation itself, the sex
was more hurried and condoms were less often used. Moreover, some of the
women selling sex in these latter circumstances were not defined as sex
workers by the men, but simply as available or 'loose women'
(Maticka-Tyndale et al, 1997). Similarly, the closer to home sex took place,
the less risky it was perceived to be. The authors conclude that future AIDS
campaigns must take account of the variety of contexts in which sex may be
bought and sold, and should avoid addressing only stereotypical scenarios
(for example, bars) in health promotion.
Several studies to
promote safer sex with male STD patients have taken place. Hadden (1997),
for example, has recently reported on findings from an experimental study
aimed at both men and women STD patients in KwaZulu Natal South Africa. In
the experimental group, information about HIV was supplemented by four
90-minute sessions of a skills-building group intervention designed to help
men and women protect themselves from HIV infection. The control group
received only information about HIV/AIDS. Single-sex sessions were held
initially. Men were shown how to use a male condom, but also showed interest
in the female condom, Unlike the women, men were found to be more
uncomfortable using anatomically correct words to discuss genitalia and sex.
Men reported in subsequent sessions that women had the right to refuse
unprotected sex, but pointed out that waiting until the point of arousal
before saying 'no' was likely to elicit an angry response. It was the timing
of requests for condom use rather than refusal which most angered men. In
common with women, men agreed that both partners should be tested for HIV if
a baby was planned.
A combined session was
also held. This session engendered much excitement and attendance was
generally higher than for other sessions. Three role-plays were included:
about sexual communication, condom negotiation and violent reactions by men
towards women. While women expressed their pain and anger and described how
they felt when physically abused, men recalled their experience of hostility
and violence towards partners. Role play involving gender role reversal was
undertaken and the men took this seriously. Subsequent to the intervention a
small, but statistically significant increase in condom use was reported by
members of the experimental group. The researchers concluded that more work
is needed with men to explore and challenge social norms that support
multiple sexual partnerships. Further research is also needed to explore
different ways of engaging men in discussions about sex and sexual rights
and responsibilities (Hadden, 1997).
Some programmes have
attempted to reach men through workplace activities. The Organisation of
Tanzanian Trades Unions (OTTU) began its work initially with women, but in
1992 the programme was expanded to reach men as well (Hadden, 1997). During
1993, 83 peer educators conducted more than 300 educational sessions in 27
workplaces, and afterwards 75% of workers participating in these sessions
reported using condoms with 'casual' or non-regular partners. The support of
managers was found to be important, and informally some reported that they
have noticed behavioural change among workers away for business who
previously might have sought out sex workers, but now do not (Hadden, 1997).
Cash et al (1997) have
built on earlier intervention research conducted with women factory workers
in Northern Thailand to develop a new programme which includes male factory
workers. Formative research conducted through focus group interviews
established that although men commonly fear HIV infection or getting a girl
pregnant, they are reluctant to take on responsibility for prevention. A
variety of educational materials was designed including a comic book story
about a male factory worker who is HIV positive. Peer leaders were also
trained, but both young men and women expressed fears about talking about
sex, STDs and HIV. The success of both single and mixed-sex sessions was
found to depend on the skills of the peer leader. Among the participants
were twelve couples who reported major improvements in communication about
HIV and sex.
The Zimbabwe AIDS
Prevention Project (ZAPP-UZ) has been following a cohort of 2,500 male
factory workers living in Harare Research to determine their sexual
attitudes and practices (Ray et al, 1996). The researchers found that most
men preferred 'dry' sex which requires their partners to use herbs and other
preparations to ensure that the vagina remains largely unlubricated during
intercourse. This practice is particularly risky in terms of HIV infection,
since it may predispose women to breaks in the epithelial barrier of the
genital tract (Ray et al, 1996). Men reported that they generally obtained
information about sex from elders and peers as they grow up, and from peers
in adulthood. Communication between sexual partners was infrequent and of
poor quality, especially between spouses. A number of men were subsequently
recruited for a peer education programme. These men were keen to learn more
about sexual practices and whether or not their was a 'scientific' basis for
their beliefs about sex. Although not fully evaluated, the programme
designers report that the peer educators who were trained developed new
attitudes towards sexual practices. Most importantly, the authors note the
importance of opportunities for men to have frank and non-judgemental
discussions with an emphasis on increased male responsibility for improved
reproductive and sexual health (Ray et al, 1996)
Men who have Sex
Although its existence
may be officially denied, sex between men occurs in every society. It is
usually stigmatised and discriminated against, and the acts concerned are
probably only occasionally understood as homosexual, bisexual or 'gay'
(Giffin, 1998). One of the earliest insights from social research on HIV and
AIDS was the understanding that sexual behaviour often fails to conform to
subjective sexual identity, although the implications of this mismatch
between behaviours and identities is still relatively under-explored
(Aggleton, Khan and Parker, 1999). The situation is made more complicated by
the existence of erotic desires and the situational specificity of much sex
As Parker (1991) has
argued, erotic desires are of special importance when it comes to
understanding non-normative sexual behaviours and practices in some
cultures, especially when these involve some kind of transgression. Context
is important in making seem reasonable and acceptable patterns of behaviour
that might in other circumstances be unthinkable and impossible to enact.
The sexual segregation and social hierarchy characteristic of penal
establishments, military environments and some religious settings, for
example, may actually facilitate sex between men (Aggleton, Khan and Parker,
1999). While often not acknowledged and rarely discussed, the sex which
occurs in such settings can be important in determining social prestige,
gender identity within and beyond that setting, and sexual health status
both positively from the point of view of sexual fulfilment and negatively
from the point of view of HIV-related risks (see, for example, Schifter,
It has been widely
documented how across much of Mexico, Central and South America, notions of
'activity' and 'passivity' in sex remain central to the gender constructions
and identities of men who have sex with other men (see, for example,
Carrier, 1995; Moya and Garcia, 1996; Schifter and Madrigal, 1992; Parker
1991; Cáceres, 1996), although there is evidence that such 'traditional'
patterns of homo- and bisexuality have recently been overlain by the advent
of international gay culture (Roberts, 1995). Similar role defined patterns
of behaviour have been identified in Morocco and some other countries in
North Africa (see, for example, Boushaba, Imane, Himmich and Tawil, 1998).
In these contexts, a masculine identity remains largely unthreatened so long
as the penetrative role in take in anal and oral sex, or so long as the
appearance of this being the case can be sustained.
Across Asia, homosexual
behaviour has been widely reported in both Islamic (Schmitt and Sofer, 1992;
Murray and Roscoe, 1997) and non-Islamic societies. Even in contexts where
male homosexuality has long been denied, there may be well developed
homosexual networks and subcultures such as those recently documented
between male sex workers and their clients in Pakistan (Mujtaba, 1997; B.
Khan, 1997). Despite the existence of these networks and behaviours, in
perhaps the majority of Asian countries marriage remains compulsory for men,
and masculinity derives from age, economic productivity, familial
relationships, getting married and having children (Khan, 1997). As a
result, the social invisibility of homosexuality and bisexuality is
In Africa too, research
now suggests the existence of homosexual behaviour and relations in
countries as diverse as the Sudan (Ahmed and Kheir, 1992), Kenya (Standing
and Kisseka, 1989; Shepherd, 1987), Botswana (Botswana Ministry of Health,
1987) and South Africa (Gevisser and Cameron, 1995).
We are clearly dealing
with universal patterns of behaviour but it must be recognised that the
meanings given to sex vary widely between societies and even across
sub-groups within a society. Given the clandestine nature of many of the
acts concerned, and their illegality in many countries, it is perhaps not
surprising that the existence of such behaviours continues to be denied. The
challenge for efforts to promote the sexual and reproductive health of men
who have sex with other men lies in acknowledging the existence of
homosexual relations between men, the inequalities they sometimes reproduce,
and the difficulties created by stigmatisation and discrimination for
efforts to reach such men with HIV prevention messages as well as other
kinds of work.
Partly because of its
invisibility, little is known about the extent to which sex between men
facilitates HIV transmission in developing countries (McKenna, 1996). A
recent analysis of responses from over two hundred organisations surveyed,
however, suggests that sex between men has an important role to play in HIV
transmission in many contexts, with consequences for infections which may
subsequently be transmitted heterosexually, or from mother to child
There have been
relatively few well documented interventions to promote the sexual and
reproductive health of men who have sex with men in Central and Southern
America, Africa and Asia, but a recent review highlights some of the work
which has already taken place (Aggleton, Khan and Parker, 1999). Successful
projects include community based outreach work with male sex workers in
Casablanca and Marrakesh (Himmich, 1992; Boushaba, Imane, Himmich and Tawil,
1998); community work with networks of men who have sex with men in Mumbai,
Chennai and Cochin in India (Aggleton, Khan and Parker,1998); work with both
male sex workers (Tan, 1998) and other homosexually active men in the
Philippines (Nierras et al, 1992; Fleras, 1993; Tan, 1995); educational,
outreach and condom promotion activities among men who have sex with men in
Vietnam (Nguyen Friendship, 1997); work in the saunas and bath-houses of
Mexico City (McKenna, 1996); the provision of telephone help lines and
holistic workshops for men who have sex with men in Costa Rica (Madrigal and
Schifter, 1992); HIV/AIDS education workshops for gay and homosexually
active men in Lima (Cáceres et al., 1989); and a range of community based
HIV prevention activities with gay and other homosexually active men in Rio
de Janeiro (Parker and Terto Jr., 1997).
The challenge for much
of this work now lies in scaling up what has so far taken place, and
extending the remit of existing projects (where feasible) so as to engage
with the structural factors which promote discrimination, stigmatization and
repression towards men who are not exclusively heterosexual, and so as to
forge links between these projects and activities and other work to promote
greater gender and sexual equality. The barriers to the success of such work
should not, however, be underestimated. If it has been difficult to
undertake work which challenges the 'patriarchal dividend' inherent in men's
existing relationships with women, it may be doubly difficult to do so in
circumstances where programming and prevention efforts may be seen as
supporting homosexuality and forms of behaviour which have been denied,
discriminated against and stigmatised.
Gender and Care
for People Living with HIV/AIDS
Stigmatisation and blame
have characterised the HIV/AIDS epidemic since the start (Lawless et al,
1996). The manner in which people are blamed has consequences for the
provision and receipt of care. Recent research clearly demonstrates how men
are much less likely to be blamed for HIV infection than women (de Bruyn et
al, 1995; Aggleton and Warwick, 1998), and are more likely to be afforded
care by their partners, families and communities. Lawless et al., (1996)
have suggested that women living with HIV have attracted guilt and blame
partly because they are perceived to have 'failed' in their roles as
nurturers and carers. It is widely believed in many societies that only
certain 'kinds' of women (most usually sex workers and women who have many
partners) become infected. Research also suggests that women are more likely
to internalise the blame attached to them (Lawless et al, 1996).
In addition to the
increased stigmatisation of women who have become infected with HIV, the
burden of care for people with HIV/AIDS also falls on women. Aggleton and
Warwick (1998) have recently analysed findings from a series of UNAIDS
supported studies of household and community responses to HIV/AIDS in the
Dominican Republic, Mexico, India, Tanzania and Thailand. In common with a
number of other studies, the research highlights how women are central to
the provision of care for people with HIV/AIDS in all countries. Even among
gay community respondents interviewed in Mexico who received additional
support from social networks of friends and lovers, men with HIV often
returned home to receive care from their mothers and other female relatives
when very ill.
In all sites, attitudes
and responses towards people with HIV/AIDS, including the provision of care,
were strongly influenced by gender and gender norms (Aggleton and Warwick,
1998). In the Dominican Republic and Mexico, however, levels and quality of
care was also influenced by perceptions of innocence and guilt. But these
responses too showed a gender imbalance. Men, even when considered more
'blameworthy', were nonetheless comforted and taken care of. When women
needed HIV-related care, however, they generally did not expect or receive
the same level of care and support as men. Women who were sick often
returned to their parents for care since they were unlikely to receive this
from their husbands.
Even in cases where men
did offer some support and care, accounts from these recent multi-site
studies suggest that gender norms influence the nature and amount of care
that men offer. In the Kyela district of Tanzania, for example, there were
indications that 'male heads of households would wish to do more when their
partners fall ill but were curtailed by cultural definitions of maleness and
the roles defined which determine masculinity' (Aggleton and Warwick, 1998:
34). There was evidence in each of the five sites in which the multi-site
study was conducted to suggest the existence of clear double standards
governing the care given to men and women. Whereas men with HIV disease were
little questioned about how they became infected and were generally cared
for (by women), women with HIV-related conditions were frequently castigated
and blamed and received lower levels of support. Women also had to balance
responsibility for provision of care with the need to support the family
financially. In spite of such problems, however, and each of the study sites
in this multi-site investigation, they continued to provide care as mothers,
wives, neighbours and volunteers (Aggleton and Warwick, 1998).
Differences in attitudes
towards women and men with HIV, and patterns in the provision of care for
people with AIDS, are related to dominant versions of masculinity and
femininity. As discussed earlier, in a wide variety of cultural contexts
expectations of female and male sexuality differ. A clear dual standard
exists with regard to the sexual behaviour of women and men in most
cultures, so that while men are often encouraged to have large numbers of
sexual partners, women are expected to remain faithful to one sexual
partner. In addition, male sexuality is widely perceived as unrestrained and
unrestrainable. Women who become infected with STDs or HIV are often viewed
as blameworthy. Blame is less likely to be ascribed to men however, who are
assumed to have little control over their sexual urges. In addition, women
traditionally provide care for family members who are sick, while a
care-giving role is not consistent with dominant or hegemonic versions of
IV. LESSONS LEARNED
As stated earlier, most
gender sensitive programmes aiming to reduce levels of HIV-related risk
behaviour have until recently focused their work on women. Programmes and
interventions involving with men are still few and far between and, where
they do exist, formal evaluation has yet to take place. More research, and
importantly the systematic evaluation of the impact and outcomes of
HIV-related work with men, needs to take place.
While keeping in mind
the limitations of the published literature in this field, it is possible to
identify some issues which may be helpful in developing future programmes of
HIV-related work with men. These include recognising that:
masculinities are socially constructed and exert pressure on men to behave
in particular ways. However, dominant or hegemonic masculinities are not
constant and do change over time. The development of alternative versions
of masculinity can, therefore, be promoted.
Gender inequalities intersect with other social inequalities such as those
organised around class, age, race, religion and sexuality. Programme
design needs to be sensitive to these patterns of interaction if gender
and sexual inequalities are to be properly addressed.
Given the intersection between gender and other inequalities, the
elimination of poverty for men and women through programmes of social
development and other means, is crucial to the prevention of HIV
Diversity among men has implications for efforts to meet their sexual and
reproductive health needs. Stereotypical images of men (for example, as
similar, as inherently 'heterosexual', or as causative of all gender
inequalities) are unlikely to be helpful in programme design and do not
afford men the opportunity to maximise their own sexual health and that of
In needs assessment and in programme design it is important to allow men
to express their needs, while keeping in mind that work will also need to
be undertaken done to ensure that all work is sensitive to the gender
inequalities which serve to silence and disadvantage women.
Men need carefully structured opportunities to consider how dominant
ideologies of masculinity, and the role relationships they reinforce, may
disadvantage them as well as their lovers, partners, families and children
The concern which many men express about the health and welfare of their
children may provide a useful way of gaining attention in relation to
Condom promotion as part of broader efforts to promote sexual and
reproductive health needs to be gender sensitive so as to ensure that
short-term increases in sales and use do not inadvertently reinforce
gender stereotypes and inequalities.
Increasing the acceptability and use of condoms among men is crucial,
since condoms provide one of the few commonly available and inexpensive
means of prevention for HIV and other STIs.
In circumstances where the male condom may be unpopular, recent research
suggests that the female condom can offer a useful means of alternative
protection against HIV and other STIs.
While work with truck drivers, migrants, the clients of sex workers, and
men who have sex with men is very important, in cultural environments
where many men routinely have multiple partners, work with men who do not
fall into any of the above especially vulnerable groups is also crucial.
Although single sex group work is important, there is evidence to suggest
that in some contexts working with men alongside women may be helpful for
both men and women.
In developing countries, as elsewhere, it is important to design,
implement and scale up programmes to promote sexual and reproductive
health among men who have sex with men. Such programmes need to recognise
the range of contexts within which such behaviour takes place, the
cultural meanings attached to sex between men, and the variations in
sexual identity that exist among men who have sex with other men.
Since women are more likely to be blamed for HIV infection, work to
counter the stigmatisation and discrimination associated with such blame
needs to take place with men as well as with women.
It is crucial for HIV-related health promotion to encourage men to take a
more active role in the care of people with HIV-related illnesses.
Poor working conditions and risks of work-related injury and mortality may
facilitate sexual risk taking and HIV transmission. These issues need to
be addressed through programmes to promote improved working conditions as
part of a broader commitment towards social development.
Research suggests that ideologies of masculinity, and the practices
associated with these, are constructed and reinforced within predominantly
male groups. Working with men in groups to promote more equitable gender
roles may therefore be helpful.
There is an on-going need to evaluate the impact and outcomes of
programmes to promote sexual and reproductive health among men and their
partners, and to disseminate findings from such work.
Given what has been
said, it is clearly important to involve men more fully than hitherto in
work linked to the prevention of HIV infection. However, responsibility for
HIV infection is not just a matter for the individual. Broader social
policies and actions are needed to inhibit the growth of the epidemic.
Unequal gender relations, as well as other inequalities, facilitate HIV
transmission and the growth of the epidemic. In the long term, greater
social and gender equality must be the aim of those seeking to enhance
sexual and reproductive health among both women and men in developing as
well as developed countries. However, given the entrenched nature of
existing gender roles, beliefs and expectations, it is unlikely that
enormous advances can be made in the short term. In the face of the global
pandemic of HIV and AIDS, it is important to think realistically about what
is attainable, and on what timescale. While it may be possible, for example,
to promote increased condom use among men, given dominant versions of
masculinity, it may be less realistic to encourage all men to remain
faithful to a primary partner.
Reference was made
earlier to the 'patriarchal dividend' which all men share. Given this
dividend, it seems unlikely that men will be prepared to relinquish the
power and privilege which patriarchy affords them, in the short term at
least. Although greater equality between men and women must be the ultimate
goal, this may take a long time to achieve. In the interim, however, it is
important that risks to the sexual health of people in developing countries
are reduced. An incremental approach, which seeks to reduce the immediate
risks of HIV infection within a gender sensitive framework may therefore be
most helpful. In the first instance, ensuring greater male participation in
programmes to promote sexual and reproductive health is crucial.
Where possible, it is
important to tackle gender inequalities and the socio-economic and other
inequalities with which they intersect, at a structural level as well.
Policy-makers need to be encouraged to develop structural and environmental
interventions to help women and men make changes in their behaviour which
might help them to protect their sexual health. These interventions might
include changes in law to protect women against male violence and to
de-criminalise sex between men. Both of these actions would render more
visible the circumstances in which HIV-related risks may be particularly
acute, and could lead to the development of more effective programmes for
prevention. The provision of education for girls, and increased
opportunities for participation in the labour market, will help to reduce
both widespread poverty and the economic dependence on men which renders
women vulnerable to sexual exploitation. Labour laws which enforce improved
working conditions and reduce injury and death in the workplace for men may
also help men change their orientation towards certain forms of risky sexual
information about men's behaviour and beliefs comes not from men themselves,
but from women. We still know little about what men think, and what they
might respond successfully to, in terms of HIV prevention. Although in the
case of domestic violence, sexual coercion and rape it may be difficult to
generate accurate accounts from men themselves, it is important to engage
men in discussion to gain an enhanced understanding of their perceptions,
attitudes and practices. Research in the following areas seems most
Accurate and up to date information is needed on men's beliefs and
practices in relation to gender, sex, sexuality and sexual health. This is
especially true in those contexts where the risk of HIV infection is high.
Systematic enquiry into sex between men is important. Since Western
typologies are rarely relevant in developing countries, it is important to
develop an understanding of the meanings attached to male to male sex in
Since risk-taking appears to be an important part of dominant ideologies
of masculinity in a number of societies, it is important to develop a
better understanding of risk-taking behaviour among men, especially among
those who work in dangerous and/or isolated environments.
Since condoms still provide the most useful means of preventing HIV
transmission, formative research is needed to identify non-stereotypical
images and messages which might appeal to men and encourage increased
This paper has suggested
that involving men more fully in HIV prevention work is essential if rates
of HIV transmission are to be reduced. This is likely to require a
considerable scaling up of existing efforts and, in the absence of new
resources, some re-orientation of existing gender sensitive programmes and
interventions, many of which currently work with women alone. While such a
move may not be universally popular, it seems necessary if we are to ensure
that men take on greater responsibility for their own sexual and
reproductive health, and that of their partners and families. Too often in
the past it has been assumed that by working with women we will be able to
redress the profound social inequalities of gender and sexuality that exist
in the world today. While some progress has been made in this respect, too
often such work has simply increased the burden of responsibilities already
shouldered by women in the developing world. In relation to HIV/AIDS it may
also have inadvertently reinforced the idea that women are the prime
'vectors of HIV' (de Bruyn et al, 1995).
If, in future years, men
are not properly involved in work to challenge the complex inequalities of
gender and sexuality which facilitate and reinforce the transmission of HIV,
women are likely to have to take on responsibility for changing men's
ideologies and practices as well as their own. This seems profoundly unfair
and, in the face of patriarchy and the structures which reinforce it, is
unlikely to yield the desired results. Work is needed to transform existing
agendas of prevention, health promotion and development so as to make them
more sensitive to gender and sexuality as principles structuring the lives
of both women and men, and influencing HIV-related vulnerabilities in ways
which could not easily be imagined only a decade or so ago.
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