Putting sex on the table: sex, sexuality and masculinity among HIV-positive men in Nairobi, Kenya

Strategies for engaging men in HIV services

The importance of men in the global HIV response is increasingly recognised. In most settings, men are less engaged in HIV services and have worse health outcomes than women. The multiple gender, social, economic, political, and institutional factors behind these patterns are well documented. More recently, researchers have been reporting evidence on strategies aimed at improving the engagement of men in HIV services. Several promising approaches exist, including community-based outreach programmes, gender-transformative interventions to shift gender norms and practices, and the development of more responsive, male-friendly health services. Challenges remain, however, in terms of cost and sustainability, intersecting inequalities like race and class, and the difficulty of changing community-level gender norms. Future research should focus on developing theory-informed interventions and evaluations, on improving the understanding of specific subpopulations of men, and on broadening the evidence base beyond the few countries that produce most research in this field.

The theory of masculinity in studies on HIV. A systematic review

This study aimed to describe the methodological characteristics of publications on HIV and masculinity, to identify possible information gaps and determine the main thematic areas. A systematic review was conducted of gender, masculinity, HIV infection and other sexually-transmitted infections in original articles published between 1992 and 2015. Original studies published from Pubmed and Scopus were included. A total of 303 articles were identified, of which 187 were selected. Most of the studies were qualitative and the most widely used technique was the interview. Twenty-nine-point five percent of studies were performed in South Africa, 20.8% in the USA, and 3.2% in Europe. Fifteen percent of the studies were performed in heterosexuals, 12.8% in men who have sex with men, and 60% did not specify the sexual orientation of the population. Eight thematic areas were defined, the most frequent being sexuality and risk behaviours, defined by men's need to demonstrate they were sexually active and a breadwinner. Most studies on HIV and masculinity show a gender bias by not specifying the sexual identity of the population. Studies should consider diversity in sexual and cultural identity in different contexts, including in Europe, to carry out more effective HIV interventions from a masculinity perspective.

Queering the evidence: remaking homosexuality and HIV risk to 'end AIDS' in Kenya

Until recently, HIV in Africa was presumed to be driven by poverty, gender inequality and poor governance. The last decade has seen a shift in global and national public health discourses, especially in eastern Africa where new statistical evidence is used to justify prevention efforts to target Key Populations, i.e. men who have sex with men (MSM), injecting drug users, and sex workers. In this article, we focus on Kenya to examine state, NGO and community HIV treatment and prevention efforts targeting MSM, specifically male sex workers. We combine ethnographic fieldwork with a critical analysis of policy(making) and implementation practices to sketch the contours of the global, national and local forces that have combined to (re)make male homosexual sex to be understood as a practice that contributes to HIV incidence in Kenya. We also show that HIV-related MSM programmes in Kenya primarily enrol male sex workers in HIV treatment programmes, which focus on mainly on treatment adherence and pay insufficient attention to the economic and psycho-social problems experienced by male sex workers. Although upper and middle class MSM are involved in running LGTBI rights-based interventions and in mobilising male sex workers for HIV interventions, they are rarely targeted by those interventions.

Antiretroviral therapy and changing patterns of HIV stigmatisation in Entebbe, Uganda

Antiretroviral therapy (ART) has the potential to change processes of HIV stigmatisation. In this article, changing processes of stigmatisation among a group of people living with HIV (PLWH) on ART in Wakiso District, Uganda, are analysed using qualitative data from a study of PLWH's self-management of HIV on ART. There were 38 respondents (20 women, 18 men) who had been taking ART for at least 1 year. They were purposefully selected from government and non-government ART providers. Two in-depth interviews were held with each participant. Processes of reduced self-stigmatisation were clearly evident, caused by the recovery of their physical appearance and support from health workers. However most participants continued to conceal their status because they anticipated stigma; for example, they feared gossip, rejection and their status being used against them. Anticipated stigma was gendered: women expressed greater fear of enacted forms of stigma such as rejection by their partner; in contrast men's fears focused on gossip, loss of dignity and self-stigmatisation. The evidence indicates that ART has not reduced underlying structural drivers of stigmatisation, notably gender identities and inequalities, and that interventions are still required to mitigate and tackle stigmatisation, such as counselling, peer-led education and support groups that can help PLWH reconstruct alternative and more positive identities. A video abstract of this article can be found at: https://youtu.be/WtIaZJQ3Y_8.

The Anthropology of Life After AIDS: Epistemological Continuities in the Age of Antiretroviral Treatment

Anthropologists working on HIV are increasingly reframing their research as taking place in “the age of treatment,” marking a shift from “the age of AIDS.” The age of treatment is characterized by the increasing biomedicalization of HIV, which has come about as a result of improved pharmaceutical and surveillance technologies and the presumption by international experts in global health that HIV could be eradicated in the near future through biomedical interventions. Despite this radical transformation, I argue that there are many important epistemological continuities for anthropologists researching HIV/AIDS in the twenty-first century. This review identifies such continuities between anthropological research conducted prior to and that conducted since the availability of life-saving treatment for HIV.

Why do men often not use condoms in their relationships with casual sexual partners in Uganda?

With a focus on Uganda, this paper examines men's condom use in sexual relationships with casual partners and what this might tell us about men's vulnerability to HIV-infection. We carried out repeat interviews with 31 men attending a clinic serving women at high risk for HIV infection and their partners in Kampala. We found that the experience of condom-less sex in the men's youth, itself the outcome of a restrictive home environment, was perceived as influencing later unsafe sexual behaviour. Peer pressure encouraged men to have multiple partners. Alcohol negatively affected condom use. Men often opted not to use a condom with women they thought looked healthy, particularly if they had had sex with the same woman before. Some men who were HIV-positive said they saw little point in using condoms since they were already infected. A concerted effort is required to reach men, like those in our study, to halt HIV and the transmission of other sexually transmitted infections.

Sex is never the same: men's perspectives on refusing circumcision from an in-depth qualitative study in Kwaluseni, Swaziland

Faced with an HIV prevalence of 31% among 18- to 49-year-olds, Swaziland developed a male circumcision policy in 2009, following compelling scientific evidence from three randomised controlled trials. Utilising United States Agency for International Development funds, the state set out to circumcise 80% of adult men in 2011. Only 8667 of the targeted 150,000 men were circumcised during the campaign. This paper presents findings from a 2012 to 2013 in-depth qualitative study among Swazi men. Methods included 13 focus group discussions, 20 in-depth interviews, 16 informal interviews and participant observation. We argue that the campaign's failure can be partly explained by the fact that circumcision was perceived as a threat to Swazi masculinities, a factor hardly considered in the planning of the intervention. Results show that men believed circumcision resulted in reduced penis sensitivity, reduced sexual pleasure and adverse events such as possible mistakes during surgery and post-operative complications that could have negative effects on their sexual lives. Given the conflicting state of scientific data about the effects of circumcision on sexuality or sexual pleasure, this study addresses important lacunae, while also demonstrating the need for more research into the relationship between sexuality, masculinity and health interventions seeking to involve men.

Peer mentors, mobile phone and pills: collective monitoring and adherence in Kenyatta National Hospital's HIV treatment programme

In 2006, the Kenyan state joined the international commitment to make antiretroviral treatment free in public health institutions to people infected with HIV. Less than a decade later, treatment has reached over 60% of those who need it in Kenya. This paper, which is based on an in-depth ethnographic case study of the HIV treatment programme at Kenyatta National Hospital, conducted intermittently between 2008 and 2014, examines how HIV-positive peer mentors encourage and track adherence to treatment regimens within and beyond the clinic walls using mobile phones and computer technology. This research into the everyday practices of patient monitoring demonstrates that both surveillance and adherence are collective activities. Peer mentors provide counselling services, follow up people who stray from treatment regimens, and perform a range of other tasks related to patient management and treatment adherence. Despite peer mentors’ involvement in many tasks key to encouraging optimal adherence, their role is rarely acknowledged by co-workers, hospital administrators, or public health officials. Following a biomedical paradigm, adherence at Kenyatta and in Kenya is framed by programme administrators as something individual clients must do and for which they must be held accountable. This framing simultaneously conceals the sociality of adherence and undervalues the work of peer mentors in treatment programmes.

The idea of African men: dealing with the cultural contradictions of sex in academia and in Kenya

In this paper, I reflect on the notion of 'African men' as it is employed in global health scholarship and disentangle the way the idea is used as a generative concept. I explore how this notion circulates and gets modified, adapted and reproduced by scholars, on the one hand, and by various groups of men in Africa, on the other. I argue that the use of the idea of African men as an a priori category in scholarly imagination and practice presents us with stereotypes that impede much research. I then briefly connect with what has been analysed as the hegemonic discourse on Africa as the paradigm of difference, and the history of local modes of self-presentation as Africans. In Kenya, among both men and women, the use of the phrase African men as a natural category of sexual agents has been used to explain or justify men's multiple sexual relations. Yet if we look more closely at men's experiences, it becomes clear how men are caught up in conflicting discourses of masculinity. I conclude that we need to analyse gender as a performative quality that is both constructed and meaningful.

We Are (a Measurable) Family: Affect and Audit in a Toronto HIV/AIDS Service Organisation

To celebrate its 30th anniversary, a Toronto HIV/AIDS service organisation (HASO) held an event called “Family of HIV” at its annual general meeting in 2017. A drag queen’s performance of the popular gay anthem “We Are Family” and a statement of “love” for the organisation from two clients followed regular annual meeting items like the auditor’s report and election of board directors. These actions created a complex affective and bureaucratic arrangement for an organisation formed through grassroots activism by and for a historically marginalised group (gay men infected with HIV), but that now serves a diverse group of HIV-positive people and is funded through state and private sectors, and is thus enmeshed in a set of obligations and responsibilities to various scales of stakeholders, including local, provincial and national health and welfare agencies. This article argues that the performance of family at the annual meeting privileges a particular affective arrangement of relationships between full-time staff, clients and volunteers that, not coincidentally, occurs in a bureaucratic culture emphasising data as a measurement of value and efficiency. This results in a closely surveilled form of family produced through dense personal and bureaucratic entanglements of regulation, alienation, care, conflict and anxiety.