Bringing Fear into Focus: The Intersections of HIV and Masculine Gender Norms in Cote d'Ivoire

"An exploration of the relationships between men's aspirations and HIV enabled us to explicate how HIV threatens masculine values in ways that exceed the physical or health-specific consequences of HIV."

In Côte d'Ivoire, as in other countries, men engage in care less than women at all points along the HIV care continuum. Research from across Africa suggests that prevailing narratives of masculinity are often at odds with perceptions of disease and healthcare seeking. To understand the reluctance men exhibit around HIV testing in Côte d'Ivoire, where only 24.2% of men living with HIV (MLHIV) know their HIV status, these researchers explored how an HIV-positive diagnosis potentially threatens Ivoirian men's aspirations, creating obstacles to HIV testing. They drew on men's voices to inform a conceptual framework, the Masculine Values Framework (MVF), which offers practical guidance for developing gender-sensitive HIV-focused social and behaviour change (SBC) programming to help meet the Joint United Nations Programme on HIV/AIDS (UNAIDS)'s 90-90-90 targets.

The researchers conducted 73 in-depth interviews (IDIs) and 28 focus group discussions (FGDs) with 227 Ivoirian men between November and December 2016 across 3 urban sites.

In general, fear was the primary barrier to HIV testing. Outdated perceptions of HIV treatment accessibility and effectiveness led men to view an HIV-positive diagnosis as a physical and social death sentence. Even more than a fear of illness and death, men expressed fear of the impact of HIV on non-health-related aspirations. Some men expressed preferring to die of HIV without ever knowing their status than to be diagnosed as HIV positive.

The men described 5 value domains: health, sexuality, work and financial success, family, and social status. Men saw HIV as a direct threat to their agency and strength with respect to each of these value domains. With the exception of MLHIV, participants did not mention health as an aspiration; but, when prompted, many men expressed that good health was necessary to attain or maintain their other values. These values were linked and mutually reinforcing.

With this data, the researchers created the MVF (see Figure 1, above and in the paper), which outlines the constructs of agency and strength with respect to each of the 5 core values and the threat HIV posed to each. For example, many participants described work as "what defines a man". Through perceived and real HIV-related stigmatisation, HIV threatened agency regarding work. Again, with regard to the value of social status, participants - especially those who did not feel sick - had difficulty reconciling the way they saw themselves with the way they imagined others saw them, given their mental image of an HIV-positive man. The lead author points to the fact that the communication around HIV for the last 30 years - including photos of emaciated people dying - had the intended effect of making people afraid of HIV; the downside is that people do not want to be tested.

The authors write, "These insights and a deeper understanding of the relationships between men's aspirations and HIV may inform the design of more effective social and behavior change programs aimed at increasing male engagement in the HIV care continuum. The Masculine Values Framework posits that (a) personal aspirations are just as, or more, salient to healthy men than specific health concerns; and (b) social and behavior change programs built around a robust, nuanced understanding of men's aspirations might be more effective than approaches that focus on illness or avoiding illness."

For example, one strategy informed by the MVF to increase men's engagement in the HIV care continuum in Côte d'Ivoire might be to showcase testimonials from MLHIV in treatment living lives fulfilled in the 5 value domains - instead of only focusing SBC communication around HIV testing through a lens of health.

The study's lead author concludes, "We need to change the image of HIV to one of a successful man living a fulfilled life. We need to send the message that even with a positive diagnosis, you can still have a wife and have sex and work and participate actively in the community." She indicates that the research was specific to HIV but that what has been learned about men and masculinity might be applicable to other health areas, such as family planning.