01: Background: Why VALOR?

Reaching men with HIV prevention and treatment services remains an important priority in the global HIV epidemic response. In many contexts, men utilize health care services less than women.

Nigeria’s Gender Gap

After launching and implementing the RISE program, rapidly scaling up activities, and aggressively pursuing targets, by March 2020, the team saw a clear gap emerging between men and women’s uptake of HIV services. Women’s uptake of treatment and care services was nearly twice that of men, with men lagging behind women across the treatment cascade.

Figure A. Proportion of Eligible Men on Treatment in Target States (as of March 2020)

Figure B. Number of eligible men and women on treatment by age category

Why there is a gap

Factors hindering the use of health services among men have been well documented globally. Conflicts between clinical hours and work, a feeling that health services are “for women,” and a need for privacy are reasons men commonly cite for not accessing health services.3 While many men provide logistical or convenience-related reasons, it is also well documented that norms of masculinity result in men being socialized to conceal — or even deny — vulnerability. 4,5 Studies in sub-Saharan Africa have found that men often feel embarrassed to visit health services due to masculinity norms that associate health- seeking with weakness.6 

Additional barriers to men’s participation in ANC/PMTCT include shame of learning one’s HIV status (especially in the case of a positive result) and fear of community stigmatization.7 In addition, recent HCD sprints in Zambia and Malawi and work from IPSOS/AVAC/PSI conducted in South Africa under MenStar, have illuminated the damaging role internalized trauma, shame and social/cultural conditioning can play in preventing men from accessing care. The work also found that men are often fearful that they will not have the capacity to cope with a positive diagnosis.

 

“It’s not the test I am afraid of. It’s what happens after the test. I’m not sure I have the courage to deal with all of that.” – VALOR VIP focus group member 

Many at-risk men see a positive HIV test as a gateway to loss, disgrace, and isolation. Men fear a positive result will be a cliff-dive, as everything enjoyable and worthwhile in life is changed in a moment. 8 Testing and HIV services may also trigger latent trauma experienced in the early HIV epidemic. Shocking, fear-based prevention messaging is still fresh in men’s minds, as are memories of loved ones taking older drug regimens that came with many pills and significant side-effects. 

 

“What is the point of living longer if you have to give up everything that makes life worth living? I’d rather not know and continue.”- VALOR VIP focus group member

COVID-19: An Unexpected Opportunity

The devastating effects of the COVID-19 pandemic hit fast. Health service delivery was significantly disrupted due to safety concerns with COVID-19 transmission. Curfews, social distancing mandates, quarantining, and travel/movement restrictions all limited face-to-face contact.

To address these challenges, RISE rapidly shifted focus to community-based services, and emphasized the need to minimize interpersonal contact. RISE focused on providing supportive supervision and relevant capacity building sessions using online platforms like ECHO and Zoom. These sessions helped the Government of Nigeria Staff understand the rationale for longer patient appointments, required review of clinic visits, as well as the importance of instituting stricter visitor controls to minimize the potential for COVID-19 transmission. RISE also optimized remote models of support as guided by multi-month dispensary (MMD) for three or six months, client treatment support calendars as well as partner “spoke” clinical platforms for clients to check-in for minor complaints. 

 

Figure C. VALOR Brand informed by context and regional learnings

Rather than interpreting these changes as a barrier to men accessing services, the RISE team saw an opportunity to improve programs and health services by tailoring them to needs and preferences specific to men. The focus shifted to developing target on-demand digital communications, virtual supportive pre-test counseling, and referral to community-based service delivery points.

 

Key takeaway

While the COVID pandemic has upended traditional health service delivery, it has also accelerated opportunities to bring services closer to men in settings outside of the clinic and through virtual communications platforms.

Key takeaway

While the COVID pandemic has upended traditional health service delivery, it has also accelerated opportunities to bring services closer to men in settings outside of the clinic and through virtual communications platforms.

3 ‘Clinics aren’t meant for men’: sexual health care access and seeking behaviors among men in Gauteng province, South Africa. Leichliter JS, Paz-Bailey G, Friedman AL, Habel MA, Vezi A, Sello M, Farirai T, Lewis DASAHARA J. 2011; 8(2):82-8.

4 Masculinity as a barrier to men’s use of HIV services in Zimbabwe. Skovdal M, Campbell C, Madanhire C, Mupambireyi Z, Nyamukapa C, Gregson SGlobal Health. 2011 May 15; 7():13.

5 Mburu G, Ram M, Siu G, Bitira D, Skovdal M, Holland P. Intersectionality of HIV stigma and masculinity in eastern Uganda: implications for involving men in HIV programmes. BMC Public Health. 2014. October 11;14:1061 10.1186/1471-2458-14-1061

6 28. Tumaini M. Nyamhanga, Eustace P.Y. Muhondwa, and Rose Shayo, “Masculine attitudes of superiority deter men from accessing antiretroviral therapy in Dar es Salaam, Tanzania,” Glob Health Action 2013, no. 6 (2013): 21812. http://dx.doi.org/10.3402/gha.v6i0.21812.

7 F Morfaw , L Mbuagbaw, L Thabane, C Rodrigues, AP Wunderlich, P Nana, and J Kunda, “Male Involvement in Prevention Programs of Mother to Child Transmission of HIV: A Systematic Review to Identify Barriers and Facilitators,” Syst Rev 2, no. 5 (Jan 16, 2013). doi: 10.1186/2046-4053-2-5.

8 Malone, S. Breaking the Cycle of Transmission: Increasing uptake of HIV testing, prevention and linkage to treatment among young men in South Africa. Webinar. 2019 April 17.