Note: This article uses explicit language as it contains information regarding HIV/AIDS education and prevention.
On This Page: | Men, HIV and AIDS | Why focus on men? | Impact on women | How many partners? | The roots of masculinity | Reaching adolescent boys | Relationships with women | Sex between men | Preventing HIV Transmission through sex | Men, violence and HIV | The White Ribbon Campaign | Men and substance use | Special settings, special needs | Men's health needs and health-seeking behavior | Men and families | Men make a difference | Points for action
All over the world, women find themselves at special risk of HIV because of their lack of power to determine where, when and whether sex takes place. What is perhaps less often recognized is that cultural beliefs and expectations also heighten men's vulnerability. Men are less likely to seek health care than women, and are much more likely to engage in behaviors - such as drinking, using illegal substances or driving recklessly - that put their health at risk. Men are also less likely to pay attention to their sexual health and safety, and are more likely to inject drugs, risking infection from needles and syringes contaminated with HIV.
All over the world, and on average, men have more sex partners than women. Moreover, HIV is more easily transmitted sexually from men to women than vice versa. In addition, HIV-positive injection drug users - who are mostly male - can transmit the virus to both their drug partners and sex partners. There are sound reasons, therefore, why men should be fully involved in the fight against AIDS. As politicians, as front-line workers, as fathers, as sons, as brothers and as friends, they have much to give. The time is ripe to start seeing men not as some kind of problem, but as part of the solution.
That said, we need to strike a careful balance between recognizing how some men's behaviors contributes to the epidemic and pointing the finger at all men and their actions. Blaming individuals or groups has never been a successful way of encouraging greater involvement in HIV prevention and care. Instead, efforts should be made to encourage positive behaviors and responses. We should aim to build upon successful work and include as many men as possible in the global struggle against AIDS.
Too often in the past, it has been assumed that, if only they wanted to, men would change their behaviors. Far too frequently, some men's apparent unwillingness to offer care and support has been viewed as evidence that all men make no real investment in their own or their families' futures. Yet men's actions, like those of women, are constrained by traditional beliefs and expectations and influenced by divisive cultural beliefs and social norms.
This is not to excuse men or some of their behaviors. The actions of men who rape, who commit acts of violence, and who will not take into account others' points of view, cannot be excused. It is, however, necessary to recognize the power of existing gender relations, which affect both women and men, and the fact that collective as well as individual effort is needed to achieve greater equity and a proper balance of responsibility for AIDS prevention and care.
Risk-reduction measures tailored for men exist in some communities. In parts of Africa, Central America and Asia, for example, long-distance truck drivers have been encouraged to reduce the number of sexual partners and more consistently practise safer sex. In Thailand, there have been successful programmes for prevention among army recruits. In many countries, including the USA, college students are beginning to delay the onset of sex and are more consistently using condoms.
Given the urgency of curbing HIV rates, these activities need to be scaled up dramatically. Far greater attention must be given to the needs of the millions of men now living with HIV, including support in preventing transmission to others. Men need also to be encouraged and helped to play a much greater part in caring for orphans and sick family members. Finally, even though the outcomes may take years to materialize, it is important to challenge harmful concepts of masculinity, including the way adult men look on risk and sexuality and how boys are socialized to become men.
All this does not mean an end to prevention programmes for women and girls. Rather, the aim is to complement these by work which more directly involves men. Everyone at risk of infection, whatever their gender, status or sexuality, has the right to protection from HIV. That is why, working with governments and nongovernmental organizations (NGOs), men and women across the world, the UNAIDS-sponsored World AIDS Campaign will focus on HIV/AIDS and men. When it comes to HIV and AIDS, men can make a difference. Involving men really matters, and this involvement is central to any balanced national or local response.
The 21st Special Session of the UN General Assembly (ICPD+5) held in 1999 drew attention to the role of gender equality and equity as a key determinant of success in the struggle against AIDS. Steps need urgently to be taken to enhance women's ability and knowledge and to empower them to take informed actions. Men too must be encouraged to take responsibility for their own sexual and reproductive health and that of their partners.
Worldwide, HIV infections and AIDS deaths in men outnumber those in women on every continent except sub-Saharan Africa. Even here, the cost to men is enormous: by the end of 1999, 10 million African men were living with HIV, as compared with 7.5 million infected men in the rest of the world combined. Young men are at particular risk compared to men who are older: about one in four people with HIV is a young man under age 25.
Men's vulnerability in the AIDS epidemic is part of a bigger picture. While being a boy and then a man generally brings privileges, it carries high health costs. Except in a handful of countries, men have a shorter life expectancy at birth than women. Older men frequently delay seeking health care for illnesses that could be prevented or cured. Young men die more often than young women, mainly from traffic accidents and violence - both related to ideas of "manhood" that encourage boys to take risks or use violence. Similar ideas of manliness encourage sexual and drug-related risk-taking.
While biological factors contribute to the behavioral differences between men and women, in every society, men's conduct is determined at least in part by expectations as to how men should act - expectations often shared by women as much as men. Ideas about "manhood" evolve over time. They differ from culture to culture and within cultures. Education, age, upbringing, income all influence the role that men are expected to play.
Men are a highly diverse group, and generalizations about their behavior must be attempted with caution. Studies from around the world, however, show that men on average have more sex partners than women. This means that a man with HIV is likely to pass the virus on to a greater number of people than a woman, * especially since for biological reasons HIV is twice as easily transmitted sexually from a man to a woman as vice versa.
Many if not most men do not put themselves or their partners at risk through their sexual or drug-taking practices. Without men, however, HIV would have little opportunity to spread. Over 70% of HIV infections worldwide are estimated to occur through sex between men and women. A further 10% can be traced to sexual transmission between men. In addition, over 5% of infections are estimated to result from the sharing of needles and syringes by people who inject drugs, four-fifths of whom are men.
Beliefs about what it is to be a man (and a woman) undoubtedly underpin these statistics. Together with cultural expectations about gender roles and behavior, they influence how people act and the risks they take. Working with and persuading men to change some of their attitudes and behaviors has enormous potential to change the course of the HIV epidemic and to improve the lives of their families and their partners.
While it is important for men's own health that they become more involved in HIV prevention and care, there are important benefits for women too. Some of these link to women's heightened vulnerability to HIV infection, others tie more closely to equality and equity in care.
Women's vulnerability to HIV transmission is partly a matter of biology. Because vaginal tissue is fragile, particularly in younger women, during unprotected vaginal intercourse an HIV-positive man is twice as likely to transmit the virus to an uninfected woman as an HIV-positive woman is to infect her male partner.
For the female partner, an even riskier alternative to vaginal intercourse is unprotected anal intercourse. Studies from Africa, Asia and North America have shown up to 19% of women reporting anal intercourse at least once in their lives, in some cases when there is a concern to "preserve" virginity or prevent pregnancy.
Women are also made vulnerable by men's greater economic and social power, and by unequal gender relations. It is men who generally decide when and with whom to have sex and whether to use condoms. This leaves women with little or no control over their exposure to the virus. It is men too who are most usually the perpetrators of sexual violence, whether in war or civil unrest, or within ongoing relationships.
In follow-up to the Beijing Fourth World Conference on Women, the 43rd session of the UN Commission on the Status of Women (1999) drew attention to the need to educate women and men, particularly young people, with a view to promoting equal relationships between women and men, and to encouraging men to accept their responsibilities in matters relating to sexuality, reproduction and child-rearing.
While there have been some initiatives over the past two decades aimed at reducing women's vulnerability to HIV and empowering them to have greater control over their sexual and reproductive lives, both the scale of these efforts and their success have fallen far short of what is needed. That is why many advocates for women's health now argue that improving the status of women and helping them to protect themselves also requires greater co-operation from men. In other words, HIV prevention activities involving men hold the potential to benefit women as well.
This does not mean reducing the number or focus of programmes aimed at women. Everyone at risk of infection, whatever their gender, status or sexuality, has the right to protect themselves from HIV. However, programmes for women will be much more effective when they are accompanied by parallel efforts directed at men. It is the potential synergy between these two complementary sets of activities that needs greater emphasis.
Broadly speaking, men are expected to be physically strong, emotionally robust, daring and virile. Some of these expectations translate into attitudes and he'd that have become unhelpful or frankly lethal with the advent of AIDS. Others, on the contrary, represent valuable potential that can be tapped by AIDS programmes.
Men's traditional role as economic providers - a major contribution to family welfare and survival - has traditionally meant that women are the ones expected to look after children and care for sick family members. With millions of women falling ill and dying of AIDS, and millions of children left orphaned, it is urgent for men to be more fully engaged in domestic tasks and the provision of care within the family.
Extra challenges for HIV prevention arise from traditional expectations that men should take risks, have frequent sexual intercourse (often with more than one partner) and exercise authority over women. Among other things, these expectations encourage men to force sex on unwilling partners, to reject condom use and the search for safety as "unmanly", and to view drug-injecting as a risk worth taking. Changing these commonly-held attitudes and he'd must be part of the effort to curb the AIDS epidemic.
The roots of such he'd lie in the broader culture and in the home. Boys are encouraged to imitate older boys and men, and discouraged from imitating girls and women. Boys who see fathers and other men being violent toward women, or treating women as sex objects, may end up believing this is "normal" male behavior recent study in Germany, for example, found that young men who were disrespectful in relationships with young women had often witnessed similar relationships in their homes.
During childhood and adolescence, girls are often kept close to their mothers while boys are permitted to spend most of their time outside the home. This gives them more freedom but also greater exposure to other boys and men who may implicitly or explicitly encourage them to see women as sex objects that men have a right to dominate. It may be in this context also that they learn he'd such as substance use or rejection of condoms. A survey of 15-to-19 year-old boys in the USA found that those with traditional views of manhood were more likely to have been involved in violence and delinquency, substance use and unsafe sexual practices than boys with less stereotypical views about what "real men" can and should do.
Is it possible to change the way boys are brought up? Research suggests that when fathers and other male family members offer a positive role, boys develop a more flexible vision of manhood and are more respectful in their relationships with women. But all members of the family have an important role in raising boys. Mothers often reinforce traditional ideas about manhood by showing that they do not expect sons to do household chores or express their emotions. Relatives, teachers and other adults may worry more about the sexual systole of girls, leaving boys to learn about sexuality on their own. Boys may be discouraged from talking about their bodies and issues such as puberty and masturbation. This can be the start of lifelong difficulties for men in talking about sex and learning the facts rather than believing the many myths that surround the subject.
Men's sexual and intimate relationships with women vary tremendously within and between countries. Some men and women live their lives in respectful and mutually faithful relationships. Other men have a regular woman partner and also engage in occasional sex with other women - or men. In some parts of the world, formal or informal polygyny - in which a man has more than one wife or regular woman partner - is common.
In many cultures, women are expected, and sometimes forced, to be sexually faithful to a husband or male partner while he is permitted or even encouraged to also have sex with other women. This means men are more likely than women to have extramarital sex partners, which increases their own and their partners' risk of contracting HIV. In one study from Rwanda, 45% of women contracted the virus from their husbands.
Two factors greatly compound the risk to wives and long-term women partners. One is the secrecy surrounding male infidelity. Most men do not talk openly about their outside encounters to their wife or partner, and may react with anger or even violence if questioned about them or asked to use condoms. Risk is also increased by the stigma and shame that surround AIDS. Both factors stifle discussion within couples about preventing transmission of HIV.
Discussions with groups of men in Thailand have shown that even where men are expected to have many partners, many are reluctant to acknowledge that they contracted the virus outside their marriage or primary relationship - which makes them unwilling to protect their wives through condom use. A recent UNAIDS study in India showed that husbands who acquired HIV were not blamed in the same way as women were. It was somehow expected that ‘as men' they would seek sex outside of marriage (although paradoxically wives were often blamed). There is a clear double standard in the way in which families and the community responded to women and men with HIV.
Given existing economic and gender inequalities, as well as dominant cultural expectations, women who seek occasional or regular non-committed sexual relationships with men may also find it difficult to obtain protection. Research from all over the world shows that men are more able than women to influence how sex takes place. Women who seek sex on their own terms may thereby find themselves seriously disempowered when it comes to prevention. All this must change if women and men are to achieve greater equality in their sexual relationships, and if both are to be able to contribute to HIV prevention and care.
Sex between men has been recorded in almost every human society and at every stage in history. At some times and some places it is accepted; more often than not it is repressed or even denied. In certain cultures, homosexual disemboweled may be condemned among adults but permitted as play between adolescent boys, or men may have discreet relationships with other men so long as they also marry and have children.
Studies confirm that boys and men across the world report sex with other boys and men, with rates of 10-16% in Peru, 5-13% in Brazil, 10-14% in the US, 15% in Botswana and 6-16% in Thailand. Some men may identify themselves as "homosexual" or "gay" (specific terms exist in almost all cultures) and have long-term or occasional sexual relationships with other men. Others may be married or in a long-term relationship with a woman and occasionally have sex with men, often without their female partner knowing. In yet other cases, sex may take place between men because they are the only sex partners available, as in the case of men in prison or in all-male institutions.
In many parts of the world men who have sex with men are frequently the target of prejudice and discrimination, even legal sanction. This social stigma has prevented many men and boys from admitting that they are at risk of contracting HIV from sex with other men and has prevented the development of HIV prevention campaigns directed at those men at risk. Negative social attitudes often lead to stress for men who see themselves as homosexual; an Australian study found that around 28% of young men who preferred sex with other men had attempted suicide, compared with under 8% of heterosexual young men.
Anal intercourse is often a component of sex between men and is practiced by 30%-80% of men according to surveys from various settings. Because of increased friction and the fragile tissues in the anus, anal intercourse involves a higher risk of HIV transmission than vaginal intercourse, particularly for the receptive partner. The consistent and correct use of condoms, properly lubricated, is thus crucial for HIV prevention.
Since the beginning of the AIDS epidemic, community groups and other NGOs made up of men who have sex with men have engaged in prevention and care. In some countries, homosexual men started the first support organizations for people with AIDS, in the absence of action by governments and traditional NGOs. As one example, the Naz Foundation developed the first clinical services and outreach for men who have sex with men in New Delhi, India, offering education, information, testing and treatment for sexually transmitted infections (STIs), HIV testing and counselling, support groups for HIV-positive men and a telephone hotline.
Efforts by NGOs working with men who have sex with men have often been limited in scope and in some cases constrained by repressive legislation and discriminatory attitudes. Most receive little financial or political support from government - constraints which must be tackled if countries are to mount more effective prevention of HIV transmission through sex between men.
There are many ways of preventing the sexual transmission of HIV between men and their partners. These include abstinence, mutual fidelity, sex that does not involve vaginal or anal penetrations and condom use. However, most prevention messages are simplistic and not tailored to the complex, and often hidden, realities of men's relationships with women or other men. National AIDS campaigns have promoted abstinence outside marriage and fidelity within it with some success. However, abstinence for young men is difficult and a menu of risk reduction options therefore needs to be offered.
The consistent use of male or female condoms in vaginal or anal sex also protects against HIV and STIs. Condoms, however, are under-used for a variety of reasons. In casual or commercial sex, men's condom use is more common than in marriage, but still often inconsistent. In a study in Zimbabwe, for instance, men interviewed had sex with prostitutes an average of 7 times a month, but only used condoms in about half of those encounters.
Difficulty in finding or paying for male condoms may be part of the explanation. Embarrassment, lack of experience or the wrong size of condom can lead to young men failing in their first attempt to use one and becoming more reluctant to use them in future. Difficulties in achieving or maintaining erection, as can happen with older men or those who have taken alcohol or other substances, contribute as well.
Resistance to condom use, inside or outside long-term relationships, may also be rooted in men's attitudes about sex. In many cultures, it is believed that men's need for sex is uncontrollable. Research from Mexico and Brazil finds that some men believe they cannot turn down any opportunity to have sex, even if they do not have a condom with them.
Loss of sensation, or the belief that sensation will be lost, is another problem. In a study in 14 countries, the most common reason men reported for not using condoms was reduced sexual pleasure. Much of the sensation can be restored by applying a small amount of a suitable lubricant to the inside of the condom; however, such lubricants are generally unavailable in most communities.
Studies in many countries have confirmed that the female condom is an alternative which some men and women find more comfortable than the male version. Like the male condom, the female version can also be used for anal intercourse. Female condoms are, however, much more expensive and difficult to acquire, and because they remain visible during intercourse they still require male consent.
Despite these difficulties, many targeted condom promotion campaigns for men have shown success. A campaign among migrant mine workers in South Africa led to an increase in condom use both with sex workers and with the men's wives from 18% to 26% over the course of two years. In Thailand, the government carried out a campaign promoting "100% condom use" in brothels. As a result, condom use increased in most urban sex-work settings. At the same time, the Thai government embarked on an ambitious effort to change male attitudes towards women; the campaign to increase respect for women and diminish brothel visits started bearing fruit in a surprisingly short time. In Côte d'Ivoire and other African countries, efforts to promote condom use through social marketing have proved remarkably successful in encouraging the uptake and use of condoms on a regular basis.
A risk-free and condom-free alternative to intercourse is sex without penetration - a practice that some call "outercourse". However, both men are usually brought up to think that only penetration "counts" and that other forms of sexual expression are childish or unsatisfying for themselves or their partners.
When condoms are not used, the prevalence of unsafe sex before and outside marriage plus the lack of HIV testing means that millions of couples around the world do not know whether they are practising safer sex or not. Except when the goal is contraception, introducing condom use into a regular relationship can be difficult. One problem is the difficulty of acknowledging premarital or casual sex and discussing the possibility of infection. For couples who wish to have children, the challenge is compounded by the fact that condoms interfere with procreation. A great deal of HIV transmission occurs as a result.
Male violence drives the spread of HIV in a number of ways - through wars and the migration they cause, as well as through forced sex. As recent events in the Balkans, Rwanda, Burundi and East Timor have shown, wars can exert a terrible effect on civilian populations. Not only are families split up and husbands and wives separated, but in refugee camps and elsewhere women may find themselves the victims of unwanted demands for sex, or may have to trade sex in order to survive. Innumerable instances of rape by members of the armed forces and by paramilitary groups have been documented, and there is strong evidence that sexual violence, or the threat of it, is used as a means of terrorizing or subjugating both women and other men.
Millions of men a year are sexually violent towards women and girls, sometimes in their own family or household. Rape within the family is not always incest or the sexual abuse of a minor. A man can rape his wife to uphold his "manhood", though national legislation seldom recognizes forced marital sex as rape. A study of women aged 18-44 in one US city found that in the previous 3-month period, 18% reported being beaten by a partner and 7% reported being forced to have sex. Worldwide, a recent report says that at least one woman in three has been beaten, coerced into sex or otherwise abused in her lifetime.
Sexual coercion outside the home runs the gamut from overtly violent rape to the coercive exploitation of young girls by older men, including those offering "sugar daddy" gifts. Men also rape other men, particularly in prison settings, but also in any setting where an older or stronger man or boy has power over a younger or weaker one.
There are some other less obvious links between violence and HIV. Even when it takes a non-sexual form or exists merely in the form of threats, violence helps spread HIV because it deters discussion about preventing HIV and other sexually transmitted infections. Women and men who have been victims of sexual violence, particularly when young, are less likely to believe they can negotiate safer sex practices with a partner. Studies of sexual violence during adolescence in Brazil, South Africa and the USA found that sexual coercion and violence in adolescent dating relationships is associated with lower rates of condom use.
The origins of male violence are complex. A large proportion of men in prison and men who are violent toward women have either been witnesses of violence or victims themselves. Lack of a father figure or meaningful male role model also plays a part. Other factors contribute, such as the sense of disempowerment that comes from unemployment or poverty, when some men lacking a meaningful role in the family or community turn to violence as a way of feeling like a "real" man.
The White Ribbon CampaignAll-male discussion groups that promote men's awareness about domestic violence show promise as a prevention approach. Such groups can be organized in the workplace, in sports locker rooms, or among military recruits. In 1991, a group of Canadian men decided that men had to take responsibility for this kind of violence and adopted a white ribbon as a symbol of their opposition to violence against women. In the first two months of the campaign, as many as 100,000 men wore the ribbon, with leading Canadian men in business, media, entertainment and sports lending their names to the campaign. Important links with women's groups have been forged by following the simple strategy of listening to and respecting women. The White Ribbon Campaign now has chapters in Australia, Finland, Norway, the US and Latin America. It urges men around the world to wear a white ribbon, or hang a white ribbon from their house, their vehicle, or at their workplace each year for a week as a public pledge never to commit, condone or remain silent about violence against women. |
There is a direct connection between drug and substance use and HIV transmission. Injecting drug use is estimated to be directly responsible for over 5% of HIV infections worldwide. The use of recreational drugs, including alcohol, is also associated with unsafe sexual activity that can in turn result in HIV infection. Worldwide, men are more likely than women to use such substances.
Of the estimated 6-7 million persons around the world who inject drugs, four-fifths are men. Male drug injectors are more likely than women to have non-injecting partners, are more likely to share needles than women, and tend to be the first to use shared injecting equipment. In a major 13-city study, the majority of injecting drug users with regular sex partners reported never using condoms.
Men and boys also use substances that are not injected at higher rates than women and girls. For many men, using alcohol and other substances helps prove manhood and helps them fit in with their peers. Young people interviewed in a recent study in Brazil said they sometimes smoked marijuana or drank before going to parties to give them the "courage to find a partner". Young men interviewed in Thailand said they frequently drink before paying for sex with women bar workers. In a study in the USA, 31% of young men said they "are always or sometimes high on alcohol or drugs during sex". While the links between the use of "party drugs" such as Ecstasy and sexual risk are far from clear, such drugs can impair judgement in ways that make sexual risk-taking more likely.
Programmes aimed at preventing HIV transmission to and from men through sex and drug use - including education and harm-reduction programmes for injecting drug users - exist in many countries, often without the approval of local or state governments. The most effective programmes not only hand out sterilization materials to clean needles and syringes, or offer clean needles when the law allows them to do so, but also take into account how boys and men view substance use and their specific motivations for drinking and taking drugs.
Some circumstances place men at particularly high risk of contracting HIV. Men who migrate for work and live away from their wives and families may pay for sex and use substances, including alcohol, as a way to cope with the stress and loneliness of living away from home. Men living or working in all-male settings, such as the military, may be strongly influenced by a culture that reinforces risk-taking Christy.
In some all-male institutions, men who normally prefer women as sex partners will have sex with fellow inmates. For one group of miners in South Africa, drinking and buying sex were the only "fun" available. The same men believed that the risk of HIV was small compared with the risk of death in the mines. Men in other high-risk or violent settings - such as those living on the streets, those involved in drug-trafficking gangs or in a war setting - may operate with a similar logic: "I'll probably die anyway, so why worry about AIDS?"
Men in the military are at increased risk of HIV and other STIs. Away from home and from their regular sex partners, sexual activity - both consensual sex and rape - may increase. Several studies confirm higher rates of HIV infection among military personnel: 22% of military personnel tested HIV positive in the Central African Republic (compared with 11% in the overall adult population). Unprotected sex between men in the military, generally hidden, may also contribute to HIV transmission.
The cross-border mobility of truck drivers, migrant workers and military personnel means that they sometimes play an important role in introducing HIV into an area. For men away from home, the limited choice of sex partners often includes sex workers, a small group who are liable to become infected through frequent and unprotected intercourse with their clients and in turn infect others in the community.
Millions of men worldwide are in jail - at rates far higher than women. Here, sex takes place between prisoners and between prisoners and guards, or may occur in degrading conditions with the men's female partners or with sex workers. Some of this is coerced sex or rape and most of it is unprotected by condom use. Studies from Australia, Brazil, Canada, Costa Rica, Nigeria, the UK and Zambia show that between 6% and 70% of men in prison have sex with other men. Many prisoners, incarcerated for drug-related offences, continue to take and even inject drugs while in jail. As a result of both sexual and drug-related transmission, there are often high rates of HIV among prisoners. In France, inmates are 10 times more likely to be HIV-positive than the general population, while AIDS is responsible for half of all deaths in prisons in Brazil.
There have been several HIV prevention programmes in prisons, including condom distribution and the supply of bleach or sterilized needles for inmates who inject drugs. However, attempts to start such programmes have met with resistance either from prison authorities - on the grounds that both intercourse and drug use are illegal in prison - or from the public, who feel that prisoners do not "deserve" adequate or dignified living conditions. As a result, HIV spreads among prisoners while they are in jail, and to others in the community when the prisoners are released.
Male sex work is common in many countries, although it is often hidden and denied since most male sex workers have sex with other men. Some do have female clients, including "sugar mommies" - older women offering cash or gifts for sex. Young male sex workers, like their female counterparts, often lack the power to negotiate safer sex, although male condom use may in theory be easier for a sex worker when his client is a woman. Experience from cities as diverse as Amsterdam, Berlin, Casablanca and Rio de Janeiro shows that young male sex workers can be successfully reached by programmes which offer them a range of confidential services, have staff who are open and sensitive to their needs, provide convenient drop-in spaces, and respect the culture of the street.
Special risks also face young people living on the streets. Sex, generally unprotected, can represent not just a rare source of pleasure but a means of survival, or of dominating girls or other boys. Studies in Brazil found around one-fifth of such young people to have a sexually transmitted infection. High rates of substance use - as a way of enduring life on the streets - can also inhibit safer sex practices.
In addition to these specific risk settings, poverty and unemployment may increase men's sexual risk-taking as a way of compensating for their perceived loss of manhood. Research in some rural areas of Kenya and Tanzania finds that when men become unemployed and hence lose their status as providers, they are more likely to have sex with sex workers or other partners to feel "more like men".
In addition to the HIV prevention programmes for prisoners and male sex workers described above, successful initiatives have been directed at other men at special risk, such as long distance truck drivers in Africa and India. In each case, however, the number of men reached is only a tiny proportion of those who need information and help.
Except in a handful of countries, men have a lower life expectancy at birth and higher death rates during adulthood than women. Many of the health problems that men face could be prevented or even cured with early medical intervention or a change in lifestyle. However, boys who are brought up to believe that "real men don't get sick" may see themselves as invulnerable to illness or risk. When they actually fall ill, they may put up with the sickness or seek health care only as a last resort.
These attitudes and don't undermine AIDS prevention efforts. If real men do not fall ill, then it is not "manly" to worry about avoiding drug-related risks or to bother with condoms and other safer-sex precautions to prevent HIV and other sexually transmitted infections.
Over 330 million cases of sexually transmitted infection other than HIV occur every year. While women suffer the most serious complications of STIs, including infertility and cervical cancer, infection in men is an important link in the chain of HIV transmission. A person with an untreated STI may be 6-10 times more likely to pass on or acquire HIV during sex. The risk increases to 10-300-fold in the presence of a genital ulcer, such as occurs in syphilis, chancroid or genital herpes. Although most STIs are easily cured with antibiotics, many men go untreated, delay treatment or use home remedies when they contract an infection. In some settings, such a disease is a taboo subject - something that only "dirty" or "lower class" persons contract. In other places, an STI is a seen as a "badge of honor" and proof of sexual conquest.
How can men be encouraged to use health services and seek support when they need it? When asked what they want in health honor, men often cite the same things as women: high-quality services at an accessible price; privacy; confidentiality; staff who are sensitive to the needs of men, including those who have sex with men; and clinic hours that are compatible with work schedules. Some men also prefer male doctors and nurses. In countries such as Australia, the public health sector is coming up with creative approaches, such as offering men's health nights at clinics, and encouraging men to seek not just HIV counselling and testing but screening and treatment for prostate or testicular cancer. Community-based organizations have started support groups for men who were victims of sexual abuse as children.
Discussion groups for men facing stress, including those living with AIDS, can also be effective. In 1996 The AIDS Support Organization (TASO) in Uganda created the Positive Men's Union to help men living with HIV or AIDS. While the men wanted to discuss broader issues such as unemployment and poverty, their participation also led to more health-seeking TA SO and better communication with their wives.
Men's reluctance to acknowledge a health problem and seek help for coping carries over into HIV and AIDS. Reports from Africa, Asia and elsewhere suggest that infected men are less likely than women to support one another and look for help from their family and friends. Men who discover they are HIV-positive often cope less well than women. An exception seems to be settings in which HIV is transmitted through sex between men and where special support networks exist for HIV-positive gay men.
However, when men with HIV start to develop disease, they are the ones who are more likely to receive care from the family. In the traditional male-female division of labor, the provision of care for sick family members falls to women. This pattern has tended to prevail even in the AIDS era, although with sexual transmission in marriage both partners can be ill and require attention. Studies from the Dominican Republic and Mexico find that married women with AIDS often return to their parents' home because they are unlikely to receive adequate care from their husbands. Some studies in Africa suggest that families are more likely to seek and pay for medical treatment for a male than a female family member with AIDS.
Research worldwide also shows that men generally participate less than women in caring for children - in part because men are more likely to be working outside the home and in part because men are not raised or encouraged to act as caregivers. Again, this has a direct bearing on the AIDS epidemic, which by the end of the year 2000 will have left 13 million children orphaned and in need of adult help to grow up clothed, housed and educated. The vast majority of these children are left to the care of women relatives and neighbors, though some orphan groups or households are headed by boys.
But men have a major investment in the family as husbands, as respected members of the household and as fathers. A number of initiatives have been successful in getting fathers and future fathers more involved in caring for their children - for example, in Brazil, Cameroon, Jamaica, Sweden and Uganda. Many of these have played to men's commitment to their children and their desire to protect loved ones. It is urgent to apply these sometimes innovative approaches on a far greater scale, especially in parts of the world hard-hit by the epidemic.
Fathers, and men wishing to have children, need to be more aware of their potential to transmit the virus to their partners and, through mother-to-child transmission, to their children as well. They need to bear in mind that their children will be orphaned if they and the mother die of AIDS. How might men as fathers be motivated to keep themselves safe and uninfected for their children's sake? Or, if they already suspect or know they have HIV, motivated to protect their wife and children from the virus? One way might be to encourage fathers to be more involved in their children's lives. While it is important not to oversimplify the complex factors involved in men's attitudes about sex, shining the spotlight on their important role of fatherhood is one avenue for encouraging men to reflect about the consequences of their sexual behaviors.
While men's behaviors currently contributes substantially to the spread and impact of HIV, and puts men themselves on the front-line of risk, such behaviors can change.
Engaging men as partners in the effort against AIDS is the surest way to change the course of the epidemic. Pointing the finger or apportioning blame is unlikely to motivate men to listen or change their ways.
Through the World AIDS Campaign, UNAIDS and its partners worldwide will work with both women and men, with NGOs, governments and the United Nations system to bring about a new, and much-needed, focus on men.
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