How Are Heterosexual Men Reached in HIV Prevention?
Are heterosexual men reached?
Yes and no. Many prevention programs in the U.S. have addressed the drug-using risks of heterosexual men, but few have addressed their sexual behavior risks. In the U.S., women have been the primary focus of sexual behavior change among heterosexuals. This approach fails to take into account gender and power imbalances, and does not encourage men to take responsibility for their own health or the health of their partners and family.
In the U.S., new AIDS cases are increasing most rapidly among people who were infected through injecting drug use (IDU) and heterosexual contact.1 The rise in IDU infections in heterosexual men has led to the rise in heterosexual infections in women, as more women become infected from men who are IDUs. For this reason, sexual behavior change among heterosexual men will be key to controlling the HIV epidemic for heterosexual men, women and children.
What puts men at risk?
Injection drug use poses the highest risk to heterosexual men.1 Use of other non- injected substances such as crack cocaine and alcohol can increase sexual risk taking, increases risk of HIV infection. A survey of heterosexuals in alcohol treatment programs in San Francisco, California, found HIV infection rates of 3% for men. This was considerably higher than rates of 0.5% found in a general population survey.2
Men in certain settings are at greater risk. In the U.S., 90% of prisoners are men. In 1994, AIDS cases for people in State or federal prisons reached 518 for every 100,000, as compared to 41 for every 100,000 for the general population of the U.S..3 Injection drug use, other illicit drug use and unprotected sex with other men are all risk behaviors for HIV in prison or jail.
A survey of active duty men in the U.S. Army found that heterosexual men who had sex with prostitutes had increased numbers of female partners, had non-steady partners, or had sex on the first day of acquaintance were at highest risk for HIV.4
What makes prevention difficult?
Safer sex guidelines can be at odds with some perceived male roles.5 For example, masculinity and sexuality are sometimes defined by having sex with multiple partners, in contrast to safer sex guidelines that call for reducing numbers of partners. A study of HIV positive male and female heterosexuals found that before diagnosis of positivity, men had far fewer monogamous relationships than women (4% vs. 55%). After diagnosis, none of the women, but 14% of men reported having multiple partners.6
Communication between men and women can be difficult, especially regarding condom use, disclosure of risk behaviors or HIV status. Traditional social and cultural gender roles in the U.S. often portray women, and not men, as the "communicator" in relationships, which might serve to relieve men of responsibility for communication.5 In 1995, over half of all female AIDS cases occurring via heterosexual contact were a result of sex with a male partner whose HIV risk was either unknown or unreported, showing that women are often unaware of their partner's HIV risk.1
Male violence and sexual coercion can be a barrier to safer sex. For example, a survey of Latino heterosexual men in the U.S. found that traditional Latino gender role beliefs impede condom use by encouraging sexual coercion, lowering sexual comfort and interfering with self-efficacy to use condoms.7
IDUs often lack access to sterile syringes via needle exchange/distribution programs or pharmacy sales. Access to drug treatment programs is also insufficient – at any given time, only 15% of IDUs in the U.S. are in treatment programs.8
What would an intervention for heterosexual men look like?
Unfortunately, very few programs exist in the U.S. to address heterosexual male sexual behavior. Most prevention efforts aimed at heterosexual male sexual behavior have taken place in developing countries, where the HIV epidemic continues primarily to affect heterosexuals. These have focused on clients of prostitutes, couples counseling, and condom social marketing. Interventions for heterosexual men can use multiple components, including:
Counseling both men and women. A study of discordant heterosexual couples (where one is HIV-infected and the other is not) found that counseling men and women together increased consistent use of condoms. Of the 124 couples who did use condoms consistently for vaginal and anal intercourse, none of the negative partners became infected, despite a total of about 15,000 episodes of intercourse.9
Helping men rethink notions of intimacy. Programs can address different male beliefs, and use consciousness-raising to address the notion of gender roles and coercive behaviors in men, as well as help men embrace an idea of intimacy that can work in conjunction with HIV prevention. Skills building to increase sexual impulse control can also help men deal with violence and coercion, as well as help reduce number of partners.7
Heterosexual male peer education. In addition to couples counseling, programs should provide counseling for and by men alone. Research has found that men are interested in family planning, but may not want to discuss it only with their wives or partners. Peer educators can teach and model effective preventive behaviors in settings where men may gather, such as gyms, barbershops or sporting events.10
Helping men communicate with women. Like many people in relationships, heterosexual men may find it difficult to talk about sex and love with their partners. One study of young African-American men, for example, demonstrated that regarding sex, men often say what they think their partner wants to hear.11 Programs that help increase communication skills can be effective.
Focus on men who have sex with men and women (MSMW). A survey of MSMW found that 54% of their female partners did not know about their homosexual activity, and 65% of the men had engaged in unprotected sex with their female partners.12 Helping MSMW with communication and disclosure skills, as well as skills for correct and consistent condom use can be beneficial.
Condom social marketing. In Zaire, careful consumer research produced "Prudence," a condom designed and priced to be culturally sensitive, attractive and affordable. Total sales of Prudence increased 443% from 1988 to 1989, and in many regions of Zaire, the word Prudence has become a generic substitute for the word condom.13 In the U.S., Umoja Sasa (or "Unity Now") brand condoms have been marketed in African-American neighborhoods with the slogan "protect the blood."14
What needs to be done?
Focusing HIV prevention efforts on heterosexual male sexual behavior in the U.S. can make a difference in the epidemic among men, their female partners and their offspring. As new AIDS cases are increasing most rapidly through heterosexual contact in the U.S., this new focus will take on even greater importance. Changing male cultural and socialization patterns will certainly not be an easy task, but targeted interventions can be effective. A comprehensive HIV prevention strategy uses many elements to protect as many people at risk for HIV as possible. Prevention for heterosexual men can strengthen men's roles as sex partners, husbands and fathers.