Breaking the cycle of transmission: Finding new ways to reach young men with HIV services in South Africa

Shawn Malone
Johanna Theunissen, Communications Officer, Technical Support to PEPFAR Programs, Baylor College of Medicine Children’s Foundation Malawi

South Africa’s health data demonstrate that young men are less likely to test for HIV and less likely to start treatment when diagnosed as HIV-positive. Young men living with HIV often transmit the virus to younger female partners, contributing to an inter-generational cycle of transmission. Consequently, it is important to ensure men are fully incorporated into a holistic response in order to achieve epidemic control.

It is essential to better understand men’s relationship to, perception of, and treatment at health facilities in order to improve existing trends. Population Services International (PSI), Ipsos, and Matchboxology are partnering to implement a two-phased approach: first to conduct user-centered research on individual, social, and structural barriers and enablers related to HIV testing and treatment among men, followed by the design and piloting of interventions informed by the research findings.

Shawn Malone

Project Director Shawn Malone presented the results of the qualitative and quantitative research—which used filmed shadowing and in-depth interviews with men and healthcare providers as well as a 60-minute survey with over 2,000 men—at the 2019 South African AIDS Conference.

“Despite appearances, most men are not stubborn or indifferent when it comes to HIV services,” Shawn stated. “They are scared.” HIV testing and treatment often feel like yet another burden, not a relief. Already faced with the stress and uncertainty of unemployment, financial instability, migration and violence, many men experience feelings of fatalism and depression, often compounded by unresolved grief and trauma. The dissonance between men’s aspirations and their reality can exacerbate these emotions: for example, men aspire to provide and protect their families, but may lack the capacity or means to do so. They aspire to be respected, but may feel shame about their financial or social situation.

“What we’re hearing from the men in our community workshops is that taking treatment is a daily reminder for them that they’ve failed, they’ve lost, they’ve messed up,” Shawn shared. Many men perceive that they have more to lose than they have to gain in testing for HIV, including a loss of control, identity, and lifestyle. They often fear the social consequences of an HIV diagnosis, such as being judged and shamed, and disappointing family.

“We need to find a way to allow men feel they are in control of their own lives,” Shawn noted. “How do we reframe HIV programming so that treatment is perceived as a tool or a weapon – something that helps them feel like they’re winning, they’re succeeding, they’re doing something right?”

South Africa’s health system presents further challenges at various levels. High client volumes and a shortage of healthcare workers cultivate anxiety and frustration among all involved. Providers, rushed for time, often provide scripted, didactic counselling and have limited empathy and patience for male clients who are often perceived as “a problem”. In addition, while providers may have the positive intention of “reaching” men, many men experience this as being “hunted” and may feel ambushed by provider-initiated testing and counselling, concerned about maintaining their privacy and the confidentiality of their HIV status.

PSI’s recommendations to address these findings include developing services and messages that take into account the specific barriers and motivators experienced by men, providing training and support for healthcare workers to enhance their service provision – empowering them to deliver more empathetic, client-centered care – and ensuring healthcare workers have an improved work environment which enables them to provide quality care.

While there are no easy solutions or quick fixes, a better understanding of how men relate to and experience HIV services is an essential first step in adapting and creating programming which treats them holistically – moving beyond purely physical care to address their emotional and psychosocial needs. It is this kind of insightful and thoughtful programming which may ultimately be key to closing the remaining gaps in testing and treatment initiation, and fostering long-term retention in care.

Summary slide