Men and Sex : Construction of male sexuality and the implications for HIV prevention in urban settings in Kenya and South Africa

Abstract: Background: The perspectives of heterosexual males who engage in high risk sexual behaviours with large sexual networks and concurrent partners are scarcely documented, but these are crucial in the understanding of the high HIV prevalence. Little is known about the sexual life and sexual risk reduction strategies in poor-resource, high risk settings in relation to increased access to antiretroviral treatment (ART) in sub-Saharan Africa Aims: The overall aim was to explore male sexual risk behaviours and sexual risk reduction strategies in urban resource-poor settings in sub-Saharan Africa with implications for sexually transmitted HIV and prevention strategies. Methods: In Sub-study 1 (Papers I III), twenty in-depth, open-ended interviews with South African men who had multiple and concurrent sexual partners were conducted. Sub-study 2 (Paper IV), twenty in-depth interviews were undertaken with male patients. A Thematic Question Guide with open-ended questions was used for the interviews. Sub-studies 1 and 2, a latent content analysis was used to explore the characteristics and dynamics of social and sexual relationships as well as alcohol as facilitating factors for high risk sexual behaviours (Papers I III), and sexual risk reduction strategies among men on ART (Paper IV). Sub-study 3 (paper V) was a cross-sectional study, where 515 consecutive adult male and female patients on ART were interviewed about their risk behaviours. Interviewers used structured questionnaires and SPSS for Windows (version 17.0) was used for statistical analysis. Bivariate and multivariate logistic regression models were performed to assess the association between explanatory variables and the outcomes of consistent condom use and a dichotomized number of sexual partners in the previous six months Findings: In Paper I, a high number of concurrent female sexual partners, geographic mobility and high levels of unprotected sex were common. Male core groups provided mutual economic and social support for the pursuit and maintenance of these networks. Reasons for large concurrent sexual networks (Paper II) were the perception that women were too empowered, could not be trusted, and men had a lack of control over them. Biological determinism further reinforced strong, negative perceptions of women and female sexuality, which helped polarize men s interpretation of gender constructions. A latent association between alcohol and the formation of casual sexual partnerships characterized by exchange, where the potential pathways by which alcohol use and transactional sex are linked (Paper III). Paper IV showed experience of prolonged and severe illness prior to the initiation of ART. Fear of symptom relapse was the main trigger for sexual behaviour change. Partner reduction was reported as a first option for behaviour change and condom use was perceived as more difficult as it had to be negotiated with female partners. In Paper V, almost one third of patients reported inconsistent condom use, indicating frequent unsafe sexual events. Male patients were significantly more likely to use condoms compared to females (82% versus 65%). Longer time on ART was significantly associated with consistent condom use. Multiple sexual partners were more common among married men (adjusted OR 4.38 95% CI 0.82 10.51) compared to married women. Conclusions: There are problematic gender dynamics that clearly affect HIV prevention efforts in urban resource-poor settings. Interventions targeting men at high risk of HIV need to challenge current societal norms of masculinity to help promote individual sexual riskreduction strategies. ART needs to be accompanied by other preventive interventions for increased community effectiveness to reduce the risk of an increasing number of new HIV infections among sero-discordant couples and others. This is important for the donor community and policy makers, who are the major providers of programme support within weak health systems.