Sexual and reproductive health perceptions and practices as revealed in the sexual history narratives of South African men living in a time of HIV/AIDS

Men's utilisation of sexual and reproductive health services in low- and middle-income countries: A narrative review

Background

Men have poor access to sexual and reproductive health (SRH) services globally, particularly in low- and middle-income countries (LMICs). Nevertheless, in LMIC and high-income countries (HICs), low SRH utilisation happens on account of several factors, such as individual, health system-related, and sociocultural factors. Identifying and addressing men's SRH service underutilisation remains essential to improving their sexual health and averting higher mortality and early morbidity associated with poor health seeking behaviour (HSB) among men.

Aim

This narrative review identifies factors influencing whether men do or do not utilise SRH services in LMICs.

Setting

We report on articles published in LMICs: Africa, Asia and South America.

Method

In this narrative review, we searched for quantitative and qualitative articles published between 2004 and 2021 from international databases, including Google Scholar, ScienceDirect, EBSCOhost, Scopus, PubMed, Medline, and reference lists of retrieved published articles.

Results

A total of 2219 articles were retrieved, from which 36 met the inclusion criteria. Factors contributing to poor uptake of SRH services by men included: a lack of access and availability of SRH services, poor health-seeking behaviour among men, and SRH facilities not being perceived as 'male-friendly spaces'. Furthermore, our review reveals that decreased use of SRH services is attributed to factors such as a lack of focus on men's SRH.

Conclusion

The current underutilised state of SRH services calls for urgent implementation of evidence-based interventions. Identifying men's SRH service inhibitors and enablers will assist programme managers and policymakers in designing SRH services tailored to their sexual health needs.

Contribution

Despite numerous global interventions to motivate men, the findings provide insight into the underutilisation of SRH services. The study also reveals the inadequate comprehensive investigation of men's SRH service utilisation, especially older men, to comprehend men's problems fully. Further research needs to be conducted on SRH issues, including vasectomy, mental health, and chronic conditions related to sexual and reproductive health. The analysis can assist SRH policymakers and program managers in strengthening the policies to motivate men to engage better with SRH services.

Social Correlates of HIV-Risky Behaviours among African Canadian Adolescents Living in British Columbia, Canada: A Secondary Data Analysis

Studies have linked HIV-risky behaviours among young people to several socio-contextual factors. However, the social factors that might increase African Canadian adolescents' exposure to HIV-risky behaviours, including unprotected sex and forced or multiple-sexual partnerships, have received little or no attention in the literature. Using data from the British Columbia Adolescent Health Surveys (2003-2018) and guided by intersectionality and socio-ecological frameworks, we examined the social determinants of HIV-risky behaviours (HRB) among African Canadian adolescents in British Columbia. We observed a general decline in HRB from 2008 to 2018. However, more than half (54.5%) of the 1042 who were sexually experienced in 2018 reported having 2 or more sexual partners, and nearly half reported condom-less sex. Our results demonstrate an important need to evaluate the impacts of several social factors on health outcomes for a unique, marginalized population.

How Do Iranian Men Perceive Their Sexual and Reproductive Health Situation? A Qualitative Content Analysis

Background

Males' viewpoint about sexual and reproductive health (SRH) and their situation are essential components of men's and women's health in the community. Men have been overlooked in reproduction health, especially with reproductive issues such as contraception, sexually transmitted infections (STIs), infertility, and sexual function. This study aimed to investigate the males' perceptions of their SRH situation in Iran.

Methods

A qualitative study was conducted from May 2016 to April 2017 on data retrieved through semi-structured interviews with 19 adult males aged 18 to 59 years. The participants were purposefully recruited from among populations of health centers in Alborz province, Iran. Conventional content analysis in OneNote software version 2016 was used for data analysis.

Results

Three main themes and nine categories emerged including 1) Perceived SRH needs, including "need to increase men's awareness about SRH", "need to have an accessibility to SRH services", and "need to have a high-quality sexual relationship"; 2) perceived SRH responsibilities, including "health-seeking behaviors", "sexual skills", "childbearing responsibilities", and "ethical commitment", and 3) Men' perception of trends of social and cultural norms, including "changing SRH priorities" and "changing marital prototype".

Conclusion

In this study, men perceived SRH as an important issue due to the changes in social and cultural trends, and many of their SRH needs have not yet been addressed. Hence, along with socio-economic changes, the policymakers of the health system should develop strategies and interventions to meet these needs.

Prevalence and Risk Factors for HIV Infection Among Heterosexual Men Recruited from Socializing Venues in Rural KwaZulu-Natal, South Africa

Young heterosexual men have low uptake of HIV prevention and treatment services and represent an important key population that may require novel strategies. We recruited 1271 heterosexual men, 12 years and older from socializing venues such as "shebeens", transport hubs, "spaza" shops, and community centers in rural KwaZulu-Natal, South Africa. Participants completed a questionnaire and were tested for HIV serostatus. Generalized estimating equations (GEE) with exchangeable covariance structure estimated factors independently associated with prevalent HIV infection. Median age was 25 years [Interquartile range (IQR) 21-29]. HIV prevalence was 15.5% [95% confidence interval (CI) 11.0-21.9] and increased significantly by age. Factors associated with higher odds of HIV infection were being 25 years and older [adjusted odds ratio (aOR) 4.82, 95% CI 3.47-6.69; p < 0.001), not completing high school (aOR 1.60, 95% CI 1.39-1.85; p < 0.001), not using condoms at first sex (aOR 1.43, 95% CI 1.20-1.70; p < 0.001), consuming alcohol (aOR 1.63, 95% CI 1.15-2.31; p = 0.006) or substances (aOR 1.37, 95% CI 1.31-1.44; p < 0.001), and absence of medical circumcision (aOR 2.05, 95% CI 1.71-2.44; p < 0.001). Risk was lower among those testing for HIV in last 12 months (aOR 0.54, 95% CI 0.36-0.80; p = 0.002). Greater effort is needed to implement innovative programs within settings that are easily accessible and where heterosexual men are likely to be.

Determinants of HIV testing behaviour among male South African construction workers

The global trend of poorer outcomes across the HIV treatment cascade for men has drawn attention to the importance of engaging men in prevention and treatment services. The South African construction industry is one of the economic sectors most adversely affected by HIV/AIDS. Previous research on HIV testing behaviour among workers in the industry has revealed that male workers are less likely to be tested than female workers. Given this gender differential, this study employed a field-administered survey to gather data from 450 site-based, male construction workers in Western Cape, South Africa. An integrated model comprising demographic, cognitive, and behavioural factors was then hypothesised to explain HIV testing behaviour. Bivariate analysis and structural equation modelling were then used to test the model. Findings indicate that HIV knowledge, having previously had an STI, and possessing a positive attitude towards HIV testing are terminal predictors of testing behaviour. As a strategy for positively influencing testing behaviour, employers should ensure that effective communication about HIV testing is established with workers across all levels of education and ethnic groups. Interventions relating to risky sexual behaviour need particular attention, and where possible HIV testing should be coupled with general STI screening.

'PrEP should be for men only': Young heterosexual men's views on PrEP in rural South Africa

BACKGROUND

Gaps persist in HIV testing, treatment, and prevention services for men, leading to higher attributable mortality compared to women. We sought to characterise HIV prevention knowledge, risk behaviours, and interest in pre-exposure prophylaxis (PrEP) among young men in rural South Africa.

METHODS

We conducted interviews with HIV-negative heterosexual men which were thematically analysed to identify key themes.

RESULTS

Among 31 participants, median age was 26 (IQR23-31), 77% were unemployed, 52% reported previous STI, 84% reported casual sexual partners. Men acknowledged inconsistent condom use with multiple partners, reporting high-risk sexual behaviour despite recognised risk. Mistrust between partners was common. Respondents reported willingness to take PrEP to protect themselves and their partner, though anticipated stigma and structural barriers. Men worried that if their female partner had PrEP, she would become sexually active with others.

CONCLUSIONS

In rural South Africa, young heterosexual men acknowledged high HIV-risk behaviour, expressed concern about acquiring HIV, and recognised the value of PrEP. Men were often not supportive of their female partners taking PrEP. Implementing HIV prevention services needs to incorporate young men's perspectives and may require gender-specific interventions, including addressing stigma, differentiated service delivery models such as community-based services or adapting facility services to target men.

An mHealth HIV prevention programme for youth: lessons learned from the iloveLife.mobi programme in South Africa

A mobile-based behavioural change program iloveLive.mobi was implemented to prevent HIV among young people (12-24 years) in South Africa. The mobile site offered access to sexual and reproductive health and psychosocial information through interactive learning. The site provided incentives for positive behaviour (such as HIV testing). The research aimed to evaluate the effectiveness of the iloveLife.mobi site in promoting protective behaviour of users. A mixed-methods approach was used, including document review, KAPB survey (n = 1882), group discussions (n = 68) and telephonic interviews (n = 175) with users and interviews with 46 project and community stakeholders. The SRH and psychosocial information on the site was age-appropriate and useful to young people (82.2%). The site reached young men who are generally difficult to reach with SRH information. High-frequency users reported more confidence related to condom use and HIV testing and more protective behaviour (condom use, VMMC) compared to low-frequency users. Users also reported more protective behaviour (HIV testing, VMMC, condom use) than a comparable national sample. iloveLife.mobi became a repository for learning to reach young people with health information. The research highlights key issues to consider when implementing an mHealth platform in a low- or middle-income country, where literacy levels and technical infrastructure may cause challenges.

Exploring People's Candidacy for Mobile Health-Supported HIV Testing and Care Services in Rural KwaZulu-Natal, South Africa: Qualitative Study

BACKGROUND

The use of mobile communication technologies (mHealth: mobile health) in chronic disease management has grown significantly over the years. mHealth interventions have the potential to decentralize access to health care and make it convenient, particularly in resource-constrained settings. It is against this backdrop that we aimed to codevelop (with potential users) a new generation of mobile phone-connected HIV diagnostic tests and Web-based clinical care pathways needed for optimal delivery of decentralized HIV testing, prevention, and care in low- and middle-income countries.

OBJECTIVE

The aim of this study was to understand ways in which an mHealth intervention could be developed to overcome barriers to existing HIV testing and care services and promote HIV self-testing and linkage to prevention and care in a poor, HIV hyperendemic community in rural KwaZulu-Natal, South Africa.

METHODS

A total of 54 in-depth interviews and 9 focus group discussions were conducted with potential users (including health care providers) in 2 different communities. Theoretically informed by the candidacy framework, themes were identified from the interview transcripts, manually coded, and thematically analyzed.

RESULTS

Participants reported barriers, such as fear of HIV identity, stigma, long waiting hours, clinic space, and health care workers' attitudes, as major impediments to effective uptake of HIV testing and care services. People continued to reassess their candidacy for HIV testing and care services on the basis of their experiences and how they or others were treated within the health systems. Despite the few concerns raised about new technology, mobile phone-linked HIV testing was broadly acceptable to potential users (particularly men and young people) and providers because of its privacy (individual control of HIV testing over health provider-initiated testing), convenience (individual time and place of choice for HIV testing versus clinic-based testing), and time saving.

CONCLUSIONS

Mobile phone-connected HIV testing and Web-based clinical care and prevention pathways have the potential to support access to HIV prevention and care, particularly for young people and men. Although mHealth provides a way for individuals to test their candidacy for HIV services, the barriers that can make the service unattractive at the clinic level will also need to be addressed if potential demand is to turn into actual demand.

Exploring adolescents and young people's candidacy for utilising health services in a rural district, South Africa

BACKGROUND

We use the 'candidacy framework' to describe adolescents' and young people's (AYP) experiences of health services in a rural KwaZulu-Natal district, South Africa.

METHODS

A qualitative approach was used including group discussions, in-depth and key informant interviews with a purposive sample of AYP (n = 70), community leaders (n = 15), school health teams (n = 10), and health service providers (n = 6).

RESULTS

Findings indicate tacit understanding among AYP that they are candidates for general health services. However, HIV stigma, apprehensions and misconceptions about sexual and reproductive health, and socio-cultural views which disapprove of AYP pre-marital sex undermine their candidacy for sexual and reproductive services.

CONCLUSION

Consideration and understanding of the vulnerabilities and reasons AYP exclude themselves will inform interventions to address their health needs. AYP's participation in the design of health services will increase their acceptability and encourage uptake of services.

What Role Do Masculine Norms Play in Men's HIV Testing in Sub-Saharan Africa?: A Scoping Review

Men living with HIV/AIDS in sub-Saharan Africa are less likely to test for HIV than women. We conducted a scoping review in May of 2016 to identify how masculine norms influence men's HIV testing in sub-Saharan Africa. Our review yielded a total of 13 qualitative studies from 8 countries. Masculine norms create both barriers and facilitators to HIV testing. Barriers included emotional inexpression, gendered communication, social pressures to be strong and self-reliant, and the fear that an HIV positive result would threaten traditional social roles (i.e., husband, father, provider, worker) and reduce sexual success with women. Facilitators included perceptions that HIV testing could restore masculinity through regained physical strength and the ability to re-assume the provider role after accessing treatment. Across sub-Saharan Africa, masculinity appears to play an important role in men's decision to test for HIV and further research and interventions are needed to address this link.

Risk perception and the influence on uptake and use of biomedical prevention interventions for HIV in sub-Saharan Africa: A systematic literature review

BACKGROUND

Risk perception has been found to be a crucial factor explaining inconsistent or non-use of HIV prevention interventions. Considerations of risk need to expand beyond risk of infection to also include the personal, social, emotional, and economic risks associated with prevention intervention use.

OBJECTIVES

This systematic review of qualitative peer-reviewed literature from sub-Saharan Africa examines perceptions of risk associated with HIV infection and HIV prevention intervention use.

DATA SOURCES

We searched Medline, Embase, PsychInfo, Africa Wide Info, CINAHL, and Global Health for publications and screened them for relevance.

STUDY ELIGIBILITY CRITERIA

Peer-reviewed qualitative studies published since 2003 were eligible for inclusion if they examined risk perception or uncertainty in the context of a medically regulated intervention. Only studies focusing on adults were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Included publications were quality assessed using the Hawker method and coded thematically.

RESULTS

10318 unique papers were identified, of which 29 are included. Among the themes identified, a particularly salient one was the potential of HIV prevention interventions to threaten the stability of a relationship and impact on how and when people may-or may not-choose to use prevention interventions.

LIMITATIONS

This literature review excludes grey-literature, which may have distinct valuable insights. We also excluded quantitative studies that may have challenged or triangulated our findings.

CONCLUSIONS AND IMPLICATIONS

When considering the risk of HIV acquisition, it is insufficient to examine biological risk in isolation from the personal, relational and economic costs associated with intervention use. This loss of emotional, physical, or material support may be perceived as more consequential than the prevention of a potential infection.

Echoes of old HIV paradigms: reassessing the problem of engaging men in HIV testing and treatment through women's perspectives

BACKGROUND

With the introduction of 2016 World Health Organization guidelines recommending universal antiretroviral therapy (ART), there has been increased recognition of the lack of men engaging in HIV testing and treatment. Studies in sub-Saharan Africa indicate there have been challenges engaging men in HIV testing and HIV-positive men into treatment.

METHODS

This qualitative study explored women's perspective of their male partner's attitudes towards HIV and ART and how it shapes woman's experience with ART. Data were collected through in-depth interviews and focus group discussions with HIV-positive pregnant and postpartum women on Option B+ and health care workers in Malawi and Zimbabwe. In Malawi, 19 in-depth interviews and 12 focus group discussions were conducted from September-December 2013. In Zimbabwe, 15 in-depth interviews and 21 focus-group discussions were conducted from July 2014-March 2014.

RESULTS

The findings highlighted that many men discourage their partners from initiating or adhering to ART. One of the main findings indicated that despite the many advancements in HIV care and ART regimens, there are still many lingering negative beliefs about HIV and ART from the earlier days of the epidemic. In addition to existing theories explaining men's resistance to/absence in HIV testing and treatment as a threat to their masculinity or because of female-focused health facilities, this paper argues that men's aversion to HIV may be a result of old beliefs about HIV and ART which have not been addressed.

CONCLUSIONS

Due to lack of accurate and up to date information about HIV and ART, many men discourage their female partners from initiating and adhering to ART. The effect of lingering and outdated beliefs about HIV and ART needs to be addressed through strengthened communication about developments in HIV care and treatment. Universal ART offers a unique opportunity to curb the epidemic, but successful implementation of these new guidelines is dependent on ART initiation and adherence by both women and men. Strengthening men's understanding about HIV and ART will greatly enhance women's ability to initiate and adhere to ART and improve men's health.

Using surrogate vaccines to assess feasibility and acceptability of future HIV vaccine trials in men: a randomised trial in inner-city Johannesburg, South Africa

BACKGROUND

Developing an effective HIV vaccine is the overriding priority for HIV prevention research. Enrolling and maintaining cohorts of men into HIV vaccine efficacy trials is a necessary prerequisite for the development and licensure of a safe and efficacious vaccine.

METHODS

One hundred-fifty consenting HIV-negative men were enrolled into a pilot 1:1 randomised controlled trial of immediate vaccination with a three-dose hepatitis B vaccine compared to deferred vaccination (at 12 months) to investigate feasibility and acceptability of a future HIV vaccine trial in this population. Adverse events, changes in risk behaviour, acceptability of trial procedures and motivations for participation in future trials were assessed.

RESULTS

Men were a median 25 years old (inter-quartile range = 23-29), 53% were employed, 90% secondary school educated and 67% uncircumcised. Of the 900 scheduled study visits, 90% were completed in the immediate vaccination arm (405/450) and 88% (396/450) in the delayed arm (P = 0.338). Acceptability of trial procedures and services was very high overall. However, only 65% of the deferred group strongly liked being randomised compared to 90% in the immediate group (P = 0.001). Informed consent processes were viewed favourably by 92% of the delayed and 82% of the immediate group (P = 0.080). Good quality health services, especially if provided by a male nurse, were rated highly. Even though almost all participants had some concern about the safety of a future HIV vaccine (98%), the majority were willing to participate in a future trial. Future trial participation would be motivated mainly by the potential for accessing an effective vaccine (81%) and altruism (75%), rather than by reimbursement incentives (2%).

CONCLUSIONS

Recruitment and retention of men into vaccine trials is feasible and acceptable in our setting. Findings from this surrogate vaccine trial show a high willingness to participate in future HIV vaccine trials. While access to potentially effective vaccines is important, quality health services are an equally compelling incentive for enrolment.

Conceptions of agency and constraint for HIV-positive patients and healthcare workers to support long-term engagement with antiretroviral therapy care in Khayelitsha, South Africa

In the context of the optimism around antiretroviral therapy (ART) as prevention of HIV/AIDS, addressing the barriers to long-term ART adherence is critical. This is particularly important given the tendency to individualise or use a blame discourse when exploring why HIV-infected patients "fail" to adequately adhere to ART, and not sufficiently exploring contextual reasons for poor adherence that may require varying solutions. This study took place at three clinics and one hospital in Khayelitsha, South Africa, to document the contextual factors that challenged ART adherence in this community. Interviews were conducted with 20 HIV-infected patients who had defaulted on their ART and were subsequently admitted to Khayelitsha hospital for clinical complications, and 9 ART service providers including doctors, nurses and HIV counsellors. Interviews assessed the reasons patients defaulted on ART and explored ways this could be prevented. Data from both groups were analysed collectively using thematic analysis. While the interviews revealed a landscape of environmental risks threatening adherence to ART, all patients managed to overcome the identified barriers at some point in their treatment phase, indicating the fluidity of patients' needs and decision making. Patients reported that distrustful relationships with service providers could inhibit their understanding of ART and/or interrupt their follow-up at clinics. Patients described their rationale and agency underlying non-adherence, such as testing their bodies' physical limits without ART medication. The study speaks to the need to appreciate contextual social and structural barriers related to ART adherence, and how these are negotiated differently by specific sub-groups, to support an appropriate response. It is imperative to not solely emphasise loss to follow-up but also assess patients' subjective trajectory of their ART journey, decision making and agency with adhering to ART, their relations with healthcare workers, and how these dynamics are intertwined with broader constraints in health systems.

Experiences of alcohol consumption and taking antiretroviral medication among men living with HIV in Tshwane, South Africa

Hazardous alcohol consumption may compromise optimal antiretroviral therapy (ART) adherence among patients. Adoption of hegemonic notions of masculinity may encourage health-risk behaviours, such as alcohol consumption, and discourage health-enhancing behaviours, such as ART adherence among men. This study aimed to explore linkages between masculinity, alcohol consumption, and taking ART medication among male ART recipients in South Africa. Male facilitators conducted five focus group discussions with 27 black male ART recipients aged between 28 and 65 years at five ART clinics. Eligibility criteria were: 18 years or older, at least three months on ART, and alcohol consumption in the past three months. Data were analysed inductively using thematic content analysis. The men demonstrated a masculinity that fostered commitment to taking ART. However, normative notions of masculinity in the men's social circles often compromised their timeous taking of medication. Fears of alcohol-ART interactions often led to intentional non-adherence to ART when drinking. Finally, healthcare provider-patient power dynamics seemed to prevent the men from discussing their challenges regarding alcohol use and ART adherence with their healthcare providers. Interventions that focus on addressing harmful hegemonic notions of masculinity among men are needed in community settings such as drinking establishments where men tend to socialise. Patient-centred approaches which enhance men's sense of involvement in their treatment are needed in healthcare settings.

Exploring gender perceptions of risk of HIV infection and related behaviour among elderly men and women of Ga-Rankuwa, Gauteng Province, South Africa

The literature shows that there are important differences between women and men in the underlying mechanisms of transmission of HIV infection and AIDS, as well as in the social and economic consequences of HIV/AIDS. These stem from sexual behaviour and socially constructed 'gender' differences between women and men in roles and responsibilities. Despite the fact that numerous gender-related sociocultural factors influence HIV/AIDS protective behaviours, little gender specificity is included in HIV prevention among the elderly. In order to close this gap, this study explored gender-related perceptions of risk of HIV infection among elderly men and women of Ga-Rankuwa in Gauteng Province, South Africa. This qualitative study used purposive sampling to conduct three focus group interviews with 22 women and 10 men who were above 60 years of age. Findings revealed that both genders blame each other for the spreading of HIV/AIDS. Male participants displayed the tendency to have multiple partners, whereas females accepted that males are promiscuous. Mixed perceptions about disclosure of HIV status were found. Condom use was a challenge, as men did not know how to introduce it with their wives, and some female participants indicated that men are resistant to using condoms. The elderly men also believed that women will have sex in exchange for money. It is concluded that there is a need for substantial behaviour change among both elderly males and females, which should address gender power relations. More in-depth and extensive research in this area is recommended.

Sexual Practices, Fertility Intentions, and Awareness to Prevent Mother-to-Child Transmission of HIV Among Infected Pregnant Women at the Yaounde Central Hospital

Introduction

The sexual and reproductive health of people living with HIV is fundamental for their well-being. Antiretroviral therapy and reproductive technologies have significantly improved quality of life of people living with HIV in developed countries. In sub-Saharan Africa, the epicenter of HIV, the sexual practices and fertility of women infected with HIV have been understudied.

Aim

To assess the sexual behavior, fertility intentions, and awareness of preventing mother-to-child transmission of HIV in pregnant women with HIV-negative partners in Yaounde Central Hospital (Yaounde, Cameroon).

Methods

A cross-sectional survey using a semistructured, interviewer-administered questionnaire was conducted at the antenatal unit and HIV clinic in 2014.

Main Outcome Measures

Ninety-four pregnant women infected with HIV provided consistent information on (i) sociodemographic characteristics, (ii) sexual and fertility patterns, (iii) awareness of preventing mother-to-child transmission of HIV, and (iv) their unmet needs.

Results

Although sexual desire had significantly changed since their HIV diagnosis, the women were highly sexually active. Approximately 19% of women had more than one sexual partner and 40% had regular unprotected sex during the 12-month period before the interviews (P < .0001). Twenty-nine percent of women preferred intermittent sexual intercourse and inconsistent condom use to delay pregnancy, but the abortion rate remained high. Age, marital status, and education affected women's awareness of mother-to-child transmission (P < .05); and no association existed between the number of living children and future pregnancies (r_s = −0.217; P = .036).

Conclusion

HIV-infected women living with HIV-negative partners in Cameroon expressed high sexual and fertility intentions with several unmet needs, including safer sexual practices and conception. Incorporating and supporting safe sexual educational practices and conception services in maternal care can decrease risky sexual behavior and vertical transmission.