The importance of masculinity and gender norms for understanding institutional responses to HIV testing and treatment strategies

"It's a 50/50 Thing You Know": Exploring the Multileveled Intersections of Gender and Power Within the Relationships of Young South African Men and Women

Efforts to advance sexual health globally require greater understandings of youth intimate relationship dynamics. Among 38 South African youth (21 women/17 men aged 21-30 from Durban and Soweto) we conducted qualitative cognitive interviews to explore how gender and power intersect to shape intimate relationship dynamics (October 2019-March 2021). Participants discussed perceptions and relevance of each of 13 items comprising the Sexual Relationship Power (SRP) scale, a widely used measure of gender equity, and the influence of SRP on youth sexual health. Data analysis was guided by constructivist grounded theory. The findings were organized using the socio-ecological model, revealing how gender and power intersected at multiple levels to influence youth intimate relationships. Key influencing factors included individual-level gender attitudes, male partner expectations, and women's resistance to dominance; intimate relationship-level power dynamics, consent, and intimacy; family-level household configurations and parental monitoring of daughters; and societal-level traditional gender norms. At all levels, women discussed resisting power inequities through communication and rejection of inequitable relationships. While men also displayed resistance to inequitable power structures, most upheld traditional gender norms through institutional affiliation (e.g. church) and deep-rooted socialized beliefs and attitudes. Efforts to improve youth sexual health require multileveled approaches that address inequitable power dynamics.

Adaptation and pre-test of a shortened Stepping Stones and Creating Futures intervention focused on HIV for young men in rural South Africa

Men's engagement in HIV prevention and treatment is suboptimal, including in South Africa. We sought to address this through adapting an evidence-based intervention, Stepping Stones and Creating Futures (SSCF), to strengthen its HIV content and provide a more scalable (shorter) intervention in rural South Africa. We then conducted a mixed methods pre-test of the intervention among young men aged 18-35 years. To adapt SSCF, we reviewed the current evidence base and worked with male Peer Navigators to update the SSCF theory of change (ToC) and manual. The revised intervention was ~45 hours (9 sessions) as opposed to ~63 hours and included a greater focus on HIV prevention and treatment technologies. Overall, 64% (n = 60) of men approached agreed to participate in the intervention, uptake (attending one session) among those who agreed was n = 35(58%) and retention (attending 6 or more sessions) was n = 25(71%). Qualitative data emphasized the intervention was acceptable, with young men describing it as something they liked. The qualitative data also broadly supported the intervention ToC, including the normalization of HIV in men's lives, and the importance of health for men in achieving their life goals. However, it also highlighted the need to focus more on HIV-related stigma and fear, and the importance of HIV self-testing kits in encouraging testing. We revised the ToC and manual in light of this data. The adapted SSCF is acceptable and supports the ToC. Next steps is an evaluation to look at effectiveness of the intervention.

Shifting gender norms to improve HIV service uptake: Qualitative findings from a large-scale community mobilization intervention in rural South Africa

Background

Interventions to improve HIV service uptake are increasingly addressing inequitable and restrictive gender norms. Yet comparatively little is known about which gender norms are most salient for HIV testing and treatment and how changing these specific norms translates into HIV service uptake. To explore these questions, we implemented a qualitative study during a community mobilization trial targeting social barriers to HIV service uptake in South Africa.

Methods

We conducted 55 in-depth interviews in 2018, during the final months of a three-year intervention in rural Mpumalanga province. Participants included 25 intervention community members (48% women) and 30 intervention staff/community-opinion-leaders (70% women). Data were analyzed using an inductive-deductive approach.

Results

We identified three avenues for gender norms change which, when coupled with other strategies, were described to support HIV service uptake: (1) Challenging norms around male toughness/avoidance of help-seeking, combined with information on the health and preventive benefits of early antiretroviral therapy (ART), eased men’s fears of a positive diagnosis and facilitated HIV service uptake. (2) Challenging norms about men’s expected control over women, combined with communication and conflict resolution skill-building, encouraged couple support around HIV service uptake. (3) Challenging norms around women being solely responsible for the family’s health, combined with information about sero-discordance and why both members of the couple should be tested, encouraged men to test for HIV rather than relying on their partner’s results. Facility-level barriers such as long wait times continued to prevent some men from accessing care.

Conclusions

Despite continued facility-level barriers, we found that promoting critical reflection around several specific gender norms, coupled with information (e.g., benefits of ART) and skill-building (e.g., communication), were perceived to support men’s and women’s engagement in HIV services. There is a need to identify and tailor programming around specific gender norms that hinder HIV service uptake.

Opportunities for technologically driven dialogical health communication for participatory interventions: Perspectives from male peer navigators in rural South Africa

There is increasing interest in the potential to deliver participatory dialogical HIV and intimate partner violence (IPV) prevention interventions via digital platforms, though the majority of mHealth interventions have been didactic in approach. We undertook 10 in-depth interviews with male Peer Navigators (PNs) who had been extensively trained and working on a larger intervention promoting young people's sexual and reproductive rights, in rural KwaZulu-Natal. Interviews focused on their, and their peers', use of technology in their everyday lives. Data were transcribed and translated, and subjected to thematic analysis. PNs described structural barriers to the use of technology, including poor connectivity, high data costs, and erratic electricity. They primarily used Facebook and WhatsApp for communication and highlighted how reading messages asynchronously was important to overcome connectivity challenges. PNs shared how groups were primarily for information sharing, they also discussed ‘sensitive’ issues online. Privacy was a concern, especially for conversations, and there was recognition of how confidentiality could be breached. It was also felt that WhatsApp could potentially support greater openness in discussions. We reflect on the potential for online interventions to support dialogical health communication, highlighting how dialogical health communication may be enabled through information provision, the asynchronous communication enhancing the potential for reflection, and greater participation in discussion by those who are shyer. Despite this potential there remain important risks around privacy of discussions and how to implement these approaches online.

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Qualitative research with young men showed high levels of cellphone usage.

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Emphasizes the importance of sharing information and personal discussions online.

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Suggests potential opportunities for discussion and reflection via WhatsApp.

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Recognises limitations of WhatsApp communication for health communication.

The Intersection of Inequitable Gender Norm Endorsement and HIV Stigma: Implications for HIV Care Engagement for Men in Ugandan Fishing Communities

Men's engagement in the HIV care continuum may be negatively affected by adherence to inequitable gender norms, which may be exacerbated by HIV stigma. This cross-sectional study with 300 male fisherfolk in Uganda examined the independent and interacting effects of inequitable gender norm endorsement and HIV stigma on men's missed HIV care appointments and missed antiretroviral (ARV) doses. Greater gender inequitable norm endorsement was associated with increased odds of missed HIV clinic visits (adjusted odds ratio [AOR)] 1.44, 95% CI 1.16-1.78) and a statistically significant interaction between internalized HIV stigma and inequitable gender norms on missed ARV doses was identified (AOR 5.32, 95% CI 2.60-10.86). Adherence to traditional gender norms reduces men's HIV appointment attendance, and among men with high internalized stigma, increases the likelihood of poor treatment adherence. These findings point to the need for HIV interventions that reconfigure harmful gender norms with a focus on stigma reduction.

Social Support, Food Insecurity, and HIV Stigma Among Men Living with HIV in Rural Southwestern Uganda: A Cross-Sectional Analysis

BACKGROUND

HIV stigma is one of the major barriers to HIV care due to the fear of disclosure and social discrimination. HIV stigma among men in sub-Saharan countries, including Uganda, has been linked to the fear about how HIV status might affect their status in society. HIV among men in sub-Saharan settings has been associated with feelings of shame, reduced self-worth, and self-blame for their HIV positive status. Information about HIV stigma and its associated factors among men living with HIV in rural Uganda is limited. This study assessed the burden of HIV stigma and its association with social support and food insecurity among men accessing HIV care at a rural health facility in southwestern Uganda.

METHODS

We conducted a clinic-based cross-sectional study and consecutively enrolled 252 adult men accessing HIV care at a rural health centre in southwestern Uganda. We collected information on sociodemographic information, HIV stigma, social support, and food insecurity. We fitted modified Poisson regression models to determine the associations between social support, food insecurity, and HIV stigma.

RESULTS

The mean HIV stigma score of the study participants was 70.08 (SD 19.34) and 75% reported food insecurity 5% of whom were severely food insecure. The risk of HIV stigma was lower among those aged 35 years and above (adjusted risk ratio [ARR]=0.89; 95% CI 0.83-0.96; P=0.003, those who had been on ART for more than 5 years (ARR=0.92; 95% CI=0.84-0.99; P=0.04), and those who had social support (ARR=0.99; 95% CI=0.98-0.99; P=<0.001). Food insecurity was associated with an increased risk of HIV stigma (ARR=1.07; 95% CI 1.00-1.15; P=0.03). Social support moderated the effect of food insecurity on HIV stigma (P=0.45).

CONCLUSION

Stigma is common among men living with HIV in rural Uganda and is significantly associated with food insecurity. Social support moderated the effect of severe food insecurity on HIV stigma among men living with HIV. Interventions to build social support systems and to economically empower men living with HIV should be incorporated into the mainstream HIV care clinics.

Addressing Uptake of HIV Testing and Linkage to Care Among Men in Côte d'Ivoire: An Evaluation of the Brothers for Life Program Implementation

BACKGROUND

Historically, men in sub-Saharan Africa have worse outcomes along the HIV care continuum than women. Brothers for Life (BFL) is a community-based behavior change intervention for men, adapted for Côte d'Ivoire, involving group discussions that address salient gender norms and promote HIV prevention, testing, and linkage to care with support from peer navigators. The goal of this study was to describe the BFL program as implemented in Côte d'Ivoire, evaluate program implementation, and report uptake of HIV testing and treatment among BFL participants.

SETTING

Three urban and periurban sites in Côte d'Ivoire.

METHODS

The implementation evaluation assessed the fidelity and acceptability of the BFL program and the reach of program completion, testing and peer navigation using qualitative and quantitative approaches.

RESULTS

BFL facilitation fidelity and content fidelity were high. Semistructured interviews with BFL participants indicated that men appreciated the format and content and that the BFL program helped some participants overcome their fears and adopt more positive attitudes and behaviors around testing and treatment. Assessments of reach showed that, of the 7187 BFL participants, 81% tested for HIV as part of BFL and 2.3% (135) tested HIV-positive. Of those, 76% (102) accepted peer navigator support, and 97% (131) initiated treatment. After 6 months, 100% of the 131 men who initiated treatment remained in care.

CONCLUSION

The implementation of BFL in Côte d'Ivoire successfully achieved the goals of engaging participants in discussions around HIV prevention, encouraging HIV testing, and achieving linkage to care, treatment initiation, and retention.

Results from a cluster-randomized trial to evaluate a microfinance and peer health leadership intervention to prevent HIV and intimate partner violence among social networks of Tanzanian men

Despite calls to engage men in HIV and intimate partner violence (IPV) prevention efforts, effective approaches to reach and engage men in low-resource, high-HIV prevalence settings are limited. We identified and engaged social networks of mostly young men in a study designed to evaluate the efficacy of a combined microfinance and peer health leadership intervention to prevent HIV and IPV. We conducted a cluster-randomized trial among 60 social networks locally referred to as "camps" within Dar es Salaam, Tanzania. Camps were randomly assigned (1:1) to a microfinance and peer health leadership intervention or a control condition that received a brief delayed intervention after the study's conclusion. Allocation was not masked to participants or researchers. Behavioral assessments were conducted at baseline and 30-months post-intervention launch, with biological samples drawn at 30-months to test for sexually-transmitted infections (STIs). Primary outcomes included prevalence of STIs and past-year IPV perpetration. Secondary outcomes included STI sexual risk behaviors and past-year HIV testing. Proximal intervention targets included inequitable gender norm attitudes and hope. A modified Poisson regression approach was used to estimate intention-to-treat intervention effects on outcomes assessed at the 30-month follow-up. We enrolled 1,258 men within 60 camps. Of these men, 1,029 (81.8%) completed the 30-month follow-up. There were no differences by condition in STI prevalence, IPV perpetration, or sexual risk behaviors at the 30-month follow-up. Intervention participants reported greater levels of past-year HIV testing, controlling for baseline testing (aRR 1.13 95% CI 1.005-1.28). They also reported significantly lower levels of inequitable gender norm attitudes (adjusted effect -0.11, 95% CI -0.21-0.003). We successfully engaged and retained social networks of men in this multilevel intervention study. While we did not see an effect on the primary outcomes, our intervention successfully improved HIV testing and reduced inequitable gender norm attitudes.

Intersectional Stigma and Multi-Level Barriers to HIV Testing Among Foreign-Born Black Men From the Caribbean

Testing is the entry point into the HIV care continuum that includes linkage to and retention in prevention services, and adherence to prevention strategies, including repeat HIV testing. Despite US policy approaches to expand HIV testing to diverse clinical care and community settings, disparities in HIV testing among Black populations persist. Foreign-born (FB) Black persons from the Caribbean have higher annual rates of HIV diagnosis and a higher percentage of late-stage HIV diagnosis, compared with US-born Black persons; and most HIV infections among FB Blacks are among men. In this article, we provide an overview of HIV testing barriers among FB Black men who engage in HIV risk-taking behaviors (e.g., condomless sex with male and/or female partners of unknown HIV serostatus). Barriers to HIV testing for both FB and US-born Black men, include HIV stigma (anticipated, perceived, internalized), low perceived HIV risk, medical or government mistrust, and perceived low access to testing resources. We examine beliefs about masculinity and gender roles that may perpetuate heteronormative stereotypes associated with perceptions of low HIV risk and barriers to HIV testing. We also discuss the impact of recent immigration policies on accessing HIV testing and treatment services and how intersectional stigmas and structural forms of oppression, such as racism, prejudice against select immigrant groups, and homophobia that may further amplify barriers to HIV testing among FB Black men. Finally, we review comprehensive prevention approaches, and suggest innovative approaches, that may improve the uptake of HIV testing among FB Black men.

Resourceful masculinities: exploring heterosexual Black men's vulnerability to HIV in Ontario, Canada

Objectives: Heterosexually active Black men are alleged to endorse masculine norms that increase their and their female partners' vulnerability to HIV. These norms include Black men's inability or reluctance to productively engage their own health-related personal and interpersonal vulnerabilities. We draw on data from the iSpeak research study in Ontario, Canada, to assess whether and how heterosexual Black men cope with personal and inter-personal vulnerability, namely that heterosexual Black men: avoid emotionally supportive relationships with other men (and women), which diminishes their capacity to productively acknowledge and resolve their health-related challenges; are reticent to productively acknowledge and address HIV and health on a personal level; and are pathologically secretive about their health, which compounds their vulnerability and precipitates poor health outcomes.Design: iSpeak was implemented in 2011 to 2013, and included two focus groups with HIV-positive and HIV-negative self-identified heterosexual men (N = 14) in Toronto and London, a focus group with community-based health promotion practitioners who provide HIV-related services to Black communities in Ontario (N = 6), and one-on-one interviews with four researchers distinguished for their scholarship with/among Black communities in Toronto. Participants in the men's focus group were recruited discretely through word-of-mouth. Focus groups were audiotaped and transcribed verbatim. Team members independently read the transcripts, and then met to identify, discuss and agree on the emerging themes.Results: We demonstrate that iSpeak participants (a) engage their personal and interpersonal vulnerabilities creatively and strategically, (b) complicate and challenge familiar interpretations of Black men's allegedly transgressive masculinity through their emotional and practical investment in their health, and (c) demonstrate a form of resourceful masculinity that ambiguously aligns with patriarchy.Conclusion: We conclude with a range of actionable recommendations to strengthen the discursive framework for understanding heterosexual Black men in relation to HIV and health, and substantively engaging them in community responses to HIV.

A scoping review on the role of masculine norms in men's engagement in the HIV care continuum in sub-Saharan Africa

Men living with HIV/AIDS in sub-Saharan Africa are less likely than women to be engaged at each stage of the HIV care continuum. We conducted a scoping review in May of 2016 to identify how masculine norms influence men's HIV care engagement in sub-Saharan Africa. Our review yielded a total of 17 qualitative studies from 8 countries. Six major themes emerged that demonstrated how norms of masculinity create both barriers and facilitators to care engagement. Barriers included the exacerbating effects of masculinity on HIV stigma, the notion that HIV threatened men's physical strength, ability to provide, self-reliance, and risk behavior, and the belief that clinics are spaces for women. However, some men transformed their masculine identity and were motivated to engage in care if they recognized that antiretroviral therapy could restore their masculinity by rebuilding their strength. These findings demonstrate masculinity plays an important role in men's decision to pursue and remain in HIV care across sub-Saharan Africa. We discuss implications for tailoring HIV messaging and counseling to better engage men and an agenda for future research in this area.

Masculinity and engagement in HIV care among male fisherfolk on HIV treatment in Uganda

This study explored the intersection of masculinity and HIV care engagement among fishermen and other male fisherfolk on antiretroviral therapy (ART) in Wakiso District, Uganda. We conducted 30 in-depth interviews with men on ART recruited from HIV treatment sites and used a thematic analysis approach. Since HIV diagnosis and ART initiation, men had adopted masculine identities more conducive to HIV care engagement. The masculine roles of worker and provider, husband and sexual partner and the appearance of physical strength were compromised by HIV, but restored by ART's positive effects on health. Peers also emerged as facilitators to HIV care, with men supporting each other to seek testing and treatment. However, structural and occupational barriers to HIV care associated with the masculine role of worker remained a barrier to care engagement. Findings suggest that emphasising the benefits of ART in bolstering men's ability to fulfil the roles important to them may improve the effectiveness of HIV testing and treatment messaging for men. Differentiated care models that address structural-level barriers to care, and community-level gender-transformative programming to help fishermen engage in HIV care, may be beneficial.

Factors predictive of successful retention in care among HIV-infected men in a universal test-and-treat setting in Uganda and Kenya: A mixed methods analysis

Background

Previous research indicates clinical outcomes among HIV-infected men in sub-Saharan Africa are sub-optimal. The SEARCH test and treat trial (NCT01864603) intervention included antiretroviral care delivery designed to address known barriers to HIV-care among men by decreasing clinic visit frequency and providing flexible, patient-centered care with retention support. We sought to understand facilitators and barriers to retention in care in this universal treatment setting through quantitative and qualitative data analysis.

Methods

We used a convergent mixed methods study design to evaluate retention in HIV care among adults (age > = 15) during the first year of the SEARCH (NCT01864603) test and treat trial. Cox proportional hazards regression was used to evaluate predictors of retention in care. Longitudinal qualitative data from n = 190 in-depth interviews with HIV-positive individuals and health care providers were analyzed to identify facilitators and barriers to HIV care engagement.

Results

There were 1,863 men and 3,820 women who linked to care following baseline testing. Retention in care was 89.7% (95% CI 87.0–91.8%) among men and 89.0% (86.8–90.9%) among women at one year. In both men and women older age was associated with higher rates of retention in care at one year. Additionally, among men higher CD4+ at ART initiation and decreased time between testing and ART initiation was associated with higher rates of retention. Maintaining physical health, a patient-centered treatment environment, supportive partnerships, few negative consequences to disclosure, and the ability to seek care in facilities outside of their community of residence were found to promote retention in care.

Conclusions

Features of the ART delivery system in the SEARCH intervention and social and structural advantages emerged as facilitators to retention in HIV care among men. Messaging around the health benefits of early ART start, decreasing logistical barriers to HIV care, support of flexible treatment environments, and accelerated linkage to care, are important to men’s success in ART treatment programs. Men already benefit from increased social support following disclosure of their HIV-status. Future efforts to shift gender norms towards greater equity are a potential strategy to support high levels of engagement in care for both men and women.

Gendered Social Institutions and Preventive Healthcare Seeking for Black Men Who Have Sex with Men: The Promise of Biomedical HIV Prevention

Research on gender and health, including research conducted among Black men who have sex with men (BMSM), has primarily focused on how gender norms and roles shape healthcare engagement. Here we advance that work by demonstrating how a broader theorization of gender, particularly one that moves beyond gender norms and performance to incorporate structures such as the healthcare system and the labor market, can facilitate an understanding of how gender affects preventive healthcare seeking among BMSM, particularly the uptake of pre-exposure prophylaxis (PrEP), a promising approach to alleviate HIV disparities. This article is based on a year-long ethnographic study conducted in New York City with BMSM (n = 31; three interviews each) and community stakeholders (n = 17). Two primary findings emerged: (1) the labor market systematically excluded the men in our sample, which limited their ability to access employer-sponsored healthcare. Such discrimination may promote overt demonstrations of masculinity that increase their HIV vulnerability and decrease healthcare seeking, and (2) healthcare systems are not structured to promote preventive healthcare for men, particularly BMSM. In fact, they constrained men's access to primary providers and were usually tailored to women. Applying a structural, gendered lens to men's health-in addition to the more frequently researched individual or interpersonal levels-provides insight into factors that affect healthcare seeking and HIV prevention for BMSM. These findings have implications for the design of policies and institutional reforms that could enhance the impact of PrEP among BMSM. Findings are also relevant to the management of chronic disease among men more broadly.

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.

"He Told Me to Check My Health": A Qualitative Exploration of Social Network Influence on Men's HIV Testing Behavior and HIV Self-Testing Willingness in Tanzania

Men continue to test for HIV at a low rate in sub-Saharan Africa. Recent quantitative evidence from sub-Saharan Africa indicates that encouragement to test for HIV from men’s network members is associated with higher previous HIV testing and HIV self-testing (HIVST) willingness. Leveraging this positive network influence to promote HIVST among men is a promising strategy that could increase HIV testing. This study investigated the reasons and strategies men used to encourage their peers to test for HIV and the outcomes in order to inform the development of a social network-based HIVST intervention for men called STEP (Self-Testing Education and Promotion). Twenty-three men from networks locally referred to as “camps” were interviewed to explore reasons for encouraging HIV testing, strategies to encourage HIV testing, and outcomes of HIV testing encouragement. Reasons men reported for encouraging their peers to test for HIV included awareness of their peers’ risky sexual behavior, knowing an HIV-positive peer, and having HIV testing experience. Strategies for encouraging testing included engaging in formal and informal conversations and accompanying friends to the clinic. Encouragement outcomes included HIV testing for some men while others remained untested due to lack of privacy in the clinic and fear of HIV stigma. Willingness to self-test for HIV and an interest to educate peers about HIVST were other outcomes of HIV testing encouragement. These findings underscore the potential of leveraging men’s existing HIV testing encouragement strategies to promote HIVST among their peers.

Sexual Self-Efficacy and Gender: A Review of Condom Use and Sexual Negotiation Among Young Men and Women in Sub-Saharan Africa

Sexual self-efficacy (SSE), one's perceived control of or confidence in the ability to perform a given sexual outcome, predicts sexual behavior; however, important questions remain regarding whether gender modifies observed associations. In a comprehensive review of peer-reviewed HIV-prevention literature focusing on youth (ages 10 to 25) in sub-Saharan Africa, we measured and assessed the influence of SSE on condom use and sexual refusal, overall and by gender. Our results, after reviewing 63 publications, show that SSE is inconsistently measured. Most studies measured condom use self-efficacy (CUSE) (96.8%) and/or sexual refusal self-efficacy (SRSE) (63.5%). On average, young men had higher CUSE than young women, while young women had higher SRSE than young men. While cross-sectional studies reported an association between high SSE and sexual behaviors, this association was not observed in interventions, particularly among young women who face a disproportionate risk of HIV acquisition. In all, 25% of intervention studies demonstrated that fostering CUSE increased condom use among young men only, and one of two studies demonstrated that higher SRSE led to reduced frequency of sexual activity for both men and women. Future research and HIV-prevention interventions must be gender targeted, consider improving CUSE for young men, and move beyond limited individual-level sexual behavior change frameworks.

Behavioral and Psychosocial Correlates of HIV Testing Among Male Clients of Female Sex Workers in Tijuana, Mexico

We use data collected from a sample of 400 male clients of female sex workers (FSW) to examine their HIV testing behavior. We present frequencies of HIV testing and used bivariate and multivariable analyses to assess its socio-demographic, behavioral, and psychosocial correlates. We found that the majority (55 %) of male clients of FSW in Tijuana, Mexico had never had an HIV test and the prevalence of HIV testing within the past year was low (9 %). In multivariable analyses, significant correlates of having ever tested for HIV were higher age, higher HIV knowledge score, lower sexual compulsiveness score, lower misogynistic attitudes score, having a condom break during sex with a FSW, and higher frequency of sex with a FSW while she was high. Our findings represent an important starting point for developing effective interventions to address the need to promote HIV testing among this population.

What role can gender-transformative programming for men play in increasing men's HIV testing and engagement in HIV care and treatment in South Africa?

Men are less likely than women to test for HIV and engage in HIV care and treatment. We conducted in-depth interviews with men participating in One Man Can (OMC) - a rights-based gender equality and health programme intervention conducted in rural Limpopo and Eastern Cape, South Africa - to explore masculinity-related barriers to HIV testing/care/treatment and how participation in OMC impacted on these. Men who participated in OMC reported an increased capability to overcome masculinity-related barriers to testing/care/treatment. They also reported increased ability to express vulnerability and discuss HIV openly with others, which led to greater willingness to be tested for HIV and receive HIV care and treatment for those who were living with HIV. Interventions that challenge masculine norms and promote gender equality (i.e. gender-transformative interventions) represent a promising new approach to address men's barriers to testing, care and treatment.

HIV testing, care, and treatment experiences among the steady male partners of female sex workers living with HIV in the Dominican Republic

Male steady partners of female sex workers (FSW) living with human immunodeficiency virus (HIV) represent a key population for treatment as prevention and/or pre-exposure prophylaxis interventions. This study uses data collected from male steady partners who were referred by FSW living with HIV participating in a multi-level HIV prevention and care intervention in Santo Domingo, Dominican Republic. We conducted a socio-behavioral survey and HIV testing with all men (n = 64) and 16 in-depth interviews with a sub-sample to obtain more depth. Thirty-five of the 64 participants were living with HIV; 27 were previously diagnosed and 8 were diagnosed during our study. As a result, 45% of men were members of sero-discordant sexual partnerships. Of men with no previous HIV diagnosis (n = 37), 15 had never been tested for HIV and nine had not been tested in the past two years. Ninety-three percent of men previously diagnosed with HIV reported receiving HIV care in the past 6 months and 78% were taking anti-retrovirals. Low HIV testing was partly due to men not feeling at risk for HIV, despite having an HIV-infected partner. Additionally, a lack of tailored care inhibited engagement in anti-retroviral treatment for those infected. HIV testing was low, highlighting a need for test-and-treat strategies. Men not living with HIV would benefit from regular testing and would be good candidates for pre-exposure prophylaxis. While almost all men who had been diagnosed with HIV were engaged in care and adherent to anti-retroviral therapy, future research should assess whether they are achieving optimal HIV outcomes for their health and prevention of ongoing transmission.