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 Wednesday 03 October 2007
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South Africa - The world’s biggest ARV Programme?

Lead Feature
Links & References
  • Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa
  • Overview of HIV/AIDS in South Africa
  • Joint Civil Society Monitoring Forum
  • The Treatment Monitor
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SOUTH AFRICA: A battle of the sexes over national ARV programme

Photo: Mujahid Safodien/PlusNews
Not enough men are coming forward for testing and treatment
South African men are lagging behind their female counterparts when it comes to the takeup of antiretroviral (ARV) drugs from the government's treatment programme.

A recent assessment of the government's 'Operational Plan for Comprehensive HIV/AIDS Care, Management and Treatment' by the Joint Civil Society Monitoring Forum, an NGO coalition set up to monitor the ARV rollout programme, showed that 70 percent of all people accessing ARVs at public healthcare facilities were women, despite the efforts of civil society organisations to bring more men on board.

Mokgethi Tshabalala, local programme manager of Men as Partners (MAP), a project run by EngenderHealth, an nongovernmental organisation working with HIV-positive men, told PlusNews that the main obstacle preventing men from using and promoting available services was the way in which society defined masculinity.

"A lot of what we're seeing along the lines of treatment disparities can be attributed to the social construction of men during their formative years. While it is generally acceptable for girls to 'act out' when they are ill or hurt, boys are usually regarded as sissies if they display identical emotions."

Tshabalala suggested that this "social construct" determined whether, how and when men accessed anti-AIDS care and treatment.

"We hear how some men refuse to ask for directions when they are lost, because to do so would be to admit defeat. So it's a fair assumption that the issue of pride also comes into play when men have to admit they are HIV-positive or in need of treatment."

Mindful of these concerns, MAP aims to help men understand the social norms that not only hamper their access to treatment but also fuel the spread of HIV, especially among women.

Globally, the number of HIV-positive women and girls is rising, with UNAIDS estimating in 2005 that 17.5 million were living with the HI virus, usually in settings where refusing sex or insisting on a condom was not an option.

Tshabalala also proposed establishing separate clinics for men and allocating suitable appointment times for male clients at co-ed health clinics as a solution to growing treatment numbers. "The times at public clinics [8am to 4pm] clash with the working hours of most men. This could be another reason that the number of men on ARVs at public healthcare facilities are so low."

According to the University of Cape Town's Centre for Social Science Research, 193,579 people were accessing ARVs at the end of 2005: 57.8 percent from public-sector outlets and 48.2 percent from the private sector.

Some 29 percent of ARVs were funded by medical schemes, while NGOs and churches provided for 5.5 percent, and 7.7 percent were purchased by individuals out of their own incomes.

Preserving pride at all costs

Doctor Francois Venter, of Wits University's Reproductive Health Research Unit, confirmed that the majority of people accessing treatment in the private sector could be men.

"This is true only because there are much more men than women who are currently employed in South Africa. If we look at workplace programmes in the mining industry, it should be pretty clear who is accessing treatment there," he told PlusNews.

South African mining giant Anglo American launched a comprehensive AIDS management programme in 2002, considered by some industry and public health experts as "far and away the best in the world".

The company's health service has managed to place 150 of its 28,000 HIV-positive employees on ARV treatment each month since the programme started, and in a new "messianic drive" workers are tested for HIV at least once annually.

However, Venter noted that despite the laudable efforts of most businesses, male treatment numbers were still not what they should be. He estimated that women made up 75 percent of his patients at Johannesburg General Hospital.

"It is easier to find women who are receptive to the early access of healthcare services and HIV testing, especially during pregnancy. Men, on the other hand - and this is true with all forms of illness - would rather wait until they are on death's door before seeking help. I am guessing that this was related either to stubborn pride, or incredible stupidity."

Aside from men being less available to the idea of HIV testing, it was nearly impossible to get them to accompany their partners on clinic visits to antenatal clinics because most men still perceived clinics, and especially antenatal clinics, where most of the HIV testing takes place, as not being user-friendly to men.

"The work being done by NGOs like MAP and its partners is making a difference in terms of how men now relate to the pandemic, but this exercise should not fall squarely on the shoulders of civil society groups," Venter said. "The government seriously needs to consider new approaches if it is to attract more men to its ARV programme."

Men's associations rise to the occasion

Doctor Nomonde Xundu, chief director of the health department's HIV/AIDS and TB Unit, mentioned existing associations of men funded by the government, such as Men In Partnership Against AIDS (MIPAA), which was launched in 2004 and operates under the South African National AIDS Council (SANAC).

MIPAA aims to involve men in using and participating in anti-AIDS services, but has been hampered by a lack of funds. The equivalent association for women, WIPAA, is better structured because it has been up and running since 2002 and is also better funded, which could explain the higher treatment numbers among women. "Given the importance of organisations that address the needs of men, MIPAA is exploring ways of working more closely with their sister organisation," said MIPAA director Alfred Mikosi.

Xundu commented that "broadly, men are organising themselves to address some of the [AIDS] issues at grassroots level". Two male-only clinics opened in June 2005 in Soweto, a sprawling township southwest of Johannesburg, but AIDS-awareness projects have been largely focused on the protection of vulnerable groups, such as women and young girls.

"Men, who often unwittingly fuel the vulnerability of these groups, were being ignored. As such, the Imbizo Men's Health Project was created with the support of the US President's Emergency Fund for AIDS Relief (PEPFAR)," Sibusiso Sithole, who manages of one of the clinics, told PlusNews.

PEPFAR is a US$15 billion initiative launched by President George W. Bush in 2003 to tackle the pandemic in Africa and the Caribbean.

Imbizo's clinics offer free HIV voluntary counselling and testing (VCT) services, and workshops on subjects like erectile dysfunction, parenting, depression and sexually transmitted infections (STIs) in a comfortable environment, with confidentiality guaranteed.

"Most men find it daunting to attend a clinic run by women for the benefit of women. From our group discussions here at Imbizo, we found that the majority of our clients were more comfortable with being examined by a male healthcare worker, especially if it has to do with an STI," said Sithole.

An estimated 2,000 men have been tested for HIV since the Imbizo 'drop-in' centres opened, but stigma and discrimination were preventing the numbers from climbing even higher. Sithole and his colleagues have developed a strategy to reach men who were too afraid of being seen at the clinics.

"We take our services to local [taverns and pool-halls], which are usually popular hangouts for men. Materials on AIDS education are always welcomed, but the prospect of VCT is still a scary thought for most of the guys we speak to."

Although it was evident that men were not as receptive to services for the prevention, treatment and care of HIV/AIDS as their female counterparts, Sithole was confident that the national expansion of Imbizo clinics could yield even better results.

Positive about being positive

Although not receiving the response they had hoped for, the interventions of Imbizo and its partners look promising.

Solomon Mokhorosi, a former client of the clinic, decided to be tested after his fiancé was diagnosed HIV-positive three years ago.

"We have been together for nearly nine years now, and I was not prepared to give up on the love we have for each other. Of course, there is always the question of 'What if?' when deciding to take VCT, but programmes like Imbizo for men, and the Tshwarisanang couples centre, have been a great support," Mokhorosi told PlusNews.

Tshwarisanang, which means 'hand-in-hand' in the Setswana language, was launched in 2004 to offer specialised counselling and HIV testing for couples. "Before I also got tested there was an element of blame - I might have infected my fiancé, because we hear how women are infected by partners who sleep around," he commented.

Research confirms Mokhorosi's observations: women are more than twice as likely as men to become infected because of high-risk sexual behaviour by male partners, who are usually reluctant to know their status; the HI virus is also transmitted eight times more efficiently from men to women than from women to men, as infected semen carries higher concentrations of the virus than vaginal secretions.

"My results came back negative, and so we both agreed it was time to move beyond the anger and confusion and instead explore our options as a discordant couple [in which only one partner is HIV positive]," said Mokhorosi. They have both been tested regularly, despite practising safer sex.

"If anything, this helps keep us sane by letting me know that I am not HIV-positive, and lets my fiancé know how far her infection has progressed. In the meantime, we support each other when we need to overcome the stigma that still exists. My family know about our status, but we are not yet ready to tell the future in-laws," he said. "When the time does come, I know we will get strength from each other."

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