Amigos and amistades: the role of men's social network ties in shaping HIV vulnerability in the Dominican Republic

The Ethics of Stigma in Medical Male Circumcision Initiatives Involving Adolescents in Sub-Saharan Africa

Ongoing global efforts to circumcise adolescent and adult males to reduce their risk of acquiring HIV constitute the largest public health prevention initiative, using surgical means, in human history. Voluntary medical male circumcision (VMMC) programs in Africa have significantly altered social norms related to male circumcision among previously non-circumcising groups and groups that have practiced traditional (non-medical) circumcision. One consequence of this change is the stigmatization of males who, for whatever reason, remain uncircumcised. This paper discusses the ethics of stigma with regard to uncircumcised adolescent males in global VMMC programs, particularly in certain recruitment, demand creation and social norm interventions. Grounded in our own experiences gained while conducting HIV-related ethics research with adolescents in Kenya, we argue that use of explicit or implicit stigma to increase the number of VMMC volunteers is unethical from a public health ethics perspective, particularly in campaigns that leverage social norms of masculinity. Ongoing global efforts to circumcise adolescent and adult males to reduce their risk of acquiring HIV constitute the largest public health prevention initiative, using surgical means, in human history. VMMC programs in Africa have significantly altered social norms related to male circumcision among previously non-circumcising groups and groups that have practiced traditional (non-medical) circumcision. One consequence of this change is the stigmatization of males who, for whatever reason, remain uncircumcised. This paper discusses the ethics of stigma with regard to uncircumcised adolescent males in global VMMC programs, particularly in certain recruitment, demand creation and social norm interventions. Grounded in our own experiences gained while conducting HIV-related ethics research with adolescents in Kenya, we argue that use of explicit or implicit stigma to increase the number of VMMC volunteers is unethical from a public health ethics perspective, particularly in campaigns that leverage social norms of masculinity.

Competition and humiliation: how masculine norms shape men's sexual and violent behaviors

We use data collected from in-depth interviews with men (n=30) in the Dominican Republic to explore how men's concern about being perceived as masculine influences their interactions with their social networks and how those interactions drive men's sexual behaviors and use of violence. Men's sexual and violent behaviors were shaped by the need to compete with other men for social status. This sense of competition also generated fear of humiliation for failing to provide for their families, satisfy sexual partners, or being openly disrespected. In an effort to avoid humiliation within a specific social group, men adapted their behaviors to emphasize their masculinity. Additionally, men who were humiliated recouped their masculinity by perpetrating physical or emotional violence or finding new sexual partners. These findings emphasize the need for understanding these social dynamics to better understand men's violent and sexual behaviors.

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.

The Association Between Men's Concern About Demonstrating Masculine Characteristics and Their Sexual Risk Behaviors: Findings from the Dominican Republic

Quantitative analyses exploring the relationship between masculinities and men's sexual risk behaviors have most commonly used one dimension of masculinities: men's gender ideology. Examining other dimensions may enhance our understanding of and ability to intervene upon this relationship. In this article, we examined the association between gender role conflict/stress (GRC/S)-men's concern about demonstrating masculine characteristics-and three different sexual risk behaviors (having two or more sex partners in the last 30 days; never/inconsistent condom use with non-steady partners; and drinking alcohol at last sex) among a sample of heterosexual men in the Dominican Republic who were participating in an HIV prevention intervention (n = 293). The GRC/S Scale we used was adapted for this specific cultural context and has 17 items (α = 0.75). We used logistic regression to assess the relationship between GRC/S and each sexual behavior, controlling for sociodemographic characteristics. In adjusted models, a higher GRC/S score was significantly associated with increased odds of having two or more sex partners in the past 30 days (AOR 1.33, 95 % CI 1.01-1.74), never/inconsistent condom use with non-steady partners (AOR 1.45, 95 % CI 1.04-2.01), and drinking alcohol at last sex (AOR 1.56, 95 % CI 1.13-2.17). These results highlight the importance of expanding beyond gender ideology to understanding the influence of GRC/S on men's sexual risk behaviors. Interventions should address men's concern about demonstrating masculine characteristics to reduce the social and internalized pressure men feel to engage in sexual risk behaviors.

La vida normal: living with HIV in Santo Domingo, Dominican Republic

In this study, we explore how individuals living with HIV in the Dominican Republic strive to live a 'normal' life and the consequences of this pursuit of normalcy. We conducted qualitative in-depth interviews with men (n = 20) and women (n = 20) living with HIV and receiving care at two urban clinics in Santo Domingo. We analysed the data using a combination of narrative analysis and thematic coding. We aimed to identify how fears and/or lived experiences with social rejection and HIV-related stigma and discrimination shaped participants' abilities to maintain social relationships, be economically productive and manage HIV within the context of sexual relationships. Participants used the discourse of una vida normal (a normal life) to frame their response to HIV. This pursuit of normality was driven by the social and economic pressures of living with a chronic condition in a context of HIV-related stigma; trying to keep things 'normal' further added to these pressures. We argue that the normal life discourse fails to recognise the dynamic and complex nature of negotiating this condition and may also create additional burdens for individuals living with HIV that could impact their wellbeing and preventive behaviours.

Stakeholder conceptualisation of multi-level HIV and AIDS determinants in a Black epicentre

HIV has reached epidemic proportions among African Americans in the USA but certain urban contexts appear to experience a disproportionate disease burden. Geographic information systems mapping in Philadelphia indicates increased HIV incidence and prevalence in predominantly Black census tracts, with major differences across adjacent communities. What factors shape these geographic HIV disparities among Black Philadelphians? This descriptive study was designed to refine and validate a conceptual model developed to better understand multi-level determinants of HIV-related risk among Black Philadelphians. We used an expanded ecological approach to elicit reflective perceptions from administrators, direct service providers and community members about individual, social and structural factors that interact to protect against or increase the risk for acquiring HIV within their community. Gender equity, social capital and positive cultural mores (e.g., monogamy, abstinence) were seen as the main protective factors. Historical negative contributory influences of racial residential segregation, poverty and incarceration were among the most salient risk factors. This study was a critical next step toward initiating theory-based, multi-level community-based HIV prevention initiatives.

"I Feel Like More of a Man": A Mixed Methods Study of Masculinity, Sexual Performance, and Circumcision for HIV Prevention

Ethnographic studies from numerous societies have documented the central role of male circumcision in conferring masculinity and preparing boys for adult male sexuality. Despite this link between masculinity, sexuality, and circumcision, there has been little research on these dynamics among men who have been circumcised for HIV prevention. We employed a mixed methods approach with data collected from recently circumcised men in the Dominican Republic (DR) to explore this link. We analyzed survey data collected six to 12 months post-circumcision (N = 293) as well as in-depth interviews conducted with a subsample of those men (n = 30). We found that 42% of men felt more masculine post-circumcision. In multivariate analysis, feeling more masculine was associated with greater concern about being perceived as masculine (OR = 1.70, 95% CI: 1.25-2.32), feeling more potent erections post-circumcision (OR = 2.25, 95% CI: 1.26-4.03), and reporting increased ability to satisfy their partners post-circumcision (OR = 2.30, 95% CI: 1.11-4.77). In qualitative interviews, these factors were all related to masculine norms of sexually satisfying one's partner, and men's experiences of circumcision were shaped by social norms of masculinity. This study highlights that circumcision is not simply a biomedical intervention and that circumcision programs need to incorporate considerations of masculine norms and male sexuality into their programming.

Masculinity and HIV: Dimensions of Masculine Norms that Contribute to Men's HIV-Related Sexual Behaviors

Numerous studies have documented a relationship between masculine norms and men's HIV-related sexual behaviors, but intervening upon this relationship requires a nuanced understanding of the specific aspects of masculine norms that shape men's sexual behaviors. We integrate theories on masculinities with empirical HIV research to identify specific dimensions of masculine norms that influence men's HIV-related sexual behaviors. We identify three major dimensions of masculine norms that shape men's sexual behavior: (1) uncontrollable male sex drive, (2) capacity to perform sexually, and (3) power over others. While the existing literature does help explain the relationship between masculine norms and men's sexual behaviors several gaps remain including: a recognition of context-specific masculinities, an interrogation of the positive influences of masculinity, adoption of an intersectional approach, assessment of changes in norms and behaviors over time, and rigorous evaluations of gender-transformative approaches. Addressing these gaps in future research may optimize prevention efforts.

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.

Strategies for recruiting steady male partners of female sex workers for HIV research

Steady male partners of female sex workers (FSW) are a key population for HIV prevention, but researchers face challenges finding and recruiting this population. We conducted 40 in-depth interviews with FSW and steady male partners of FSW in Santo Domingo, Dominican Republic about how to engage steady male partners in HIV research. Participants cautioned that male partners might be unwilling to participate because of discomfort disclosing intimate information and cultural norms of masculinity. They recommended inviting male partners to research offices, instead of venue-based recruitment, because it was more private and trust-promoting. Most participants suggested that FSW could refer their partners or men could refer their friends who have FSW partners. Participants emphasized that referrals could break down trust-related barriers that prevent male partners from participating. Establishing an environment of respect and trust in the research setting can aid referral processes as individuals who participate communicate their positive experiences to their networks.