Masculinity, Intimate Relationships and AIDS Prevention in Uganda

2. Masculinity,Intimate RelationshipsandAIDS Preventionin Uganda Robert Wyrod, PhD Center for AIDS Prevention Studies University of California, San Francisco

3. Roadmap • why masculinity in urban Uganda • overview key dissertation research findings • gender and AIDS prevention in Africa

4. Gender and Social Change in Africa • changing gender relations • in Africa • how does AIDS matter? • masculinity  AIDS • AIDS  masculinity

5. Why Uganda? 2005 HIV Prevalence Total 6.4% Women 7.5% Men 5.0%

7. Bwaise Town Approximately One Square Mile 47,000 people

8. Methods • October 2003 – October 2004 • ethnography/participant • observation • 69 in-depth interviews • 4 focus groups

9. Methods Participant Observation

10. Methods Participant Observation

11. Methods Participant Observation

12. Methods Participant Observation

13. Masculinity in Bwaise Uncontested Male Provider Ideal

14. Uncontested Male Provider Ideal Contested Masculine Ideals Men and Work “Proper” Gendered Division of Labor Nature of Male Authority Male Superiority “Proper” Male Sexuality Multiple Sexual Partners Masculinity in Bwaise Gender Dimension SexualityDimension

15. Masculinity and Women’s Rightsin Urban Uganda

16. Masculinity and Women’s Rights in Uganda • 1) gender inequality • men and women different - men innately superior • roots pre-colonial Buganda and colonial ideologies • remain relevant and inflected in new ways • 2) gender equity • men and women different… • but women have certain rights • disseminated thru government policies and programs • 3) gender equality • rejects innate male/female hierarchies • expansive notion women’s rights • disseminated by local NGOs and INGOs

17. Reproducing and Challenging Male Authority reactionary responses mainstream responses transgressive responses

18. Reproducing and Challenging Male Authority • reactionary responses • 34% of men • 26% of women • mainstream responses • 48% of men • 26% of women • transgressive responses • 18% of men • 48% of women

19. Women’s Rights, African Masculinities and AIDS Main Point: • institutionalization of certain aspects of women’s rights • transformations in some aspects of male authority • AIDS • AIDS is not driving force in these shifts • women’s rights also not integrated into AIDS prevention How to capitalize on such shifts with regard to AIDS prevention?

20. AIDS Prevention and Gender Relations in Africa

21. Overall HIV Prevalence 2005 Total 6.4% Women 7.5% Men 5.0%

22. Paradigms for Understanding AIDS in Africa Biological Paradigm BIOMEDICAL Concurrency Paradigm BEHAVIORAL Age-Difference Paradigm Power Paradigm STRUCTURAL

23. Biological Paradigm Women biologically more susceptible to HIV infection than men • biology destiny? • how account for regional differences in • HIV prevalence

24. Concurrency Paradigm • Simultaneous, overlapping sexual relationships • Long history of this for men in Africa • Creates dense sexual networks which fuel spread of HIV • Female concurrency exists as well • not as common • not done for same reasons • has more serious consequences for women than men

25. Age-Difference Paradigm • typically thought of as “sugar daddy” relationships • i.e. adolescent girls & older men - transactional sex • research Kenya and Zimbabwe: more myth than reality? • think beyond sugar daddies • role of more “conventional” intergenerational sex • in context of mature, generalized AIDS epidemic

26. Age-Difference Paradigm

28. Mean Age Difference between Men and Their Female PartnersHarare 2002 Age gap decreases with less stable relationships

29. Consistent Condom Use by Age of PartnerHarare 2002 Condom use increases with younger partners Condom use increases with casual partners

30. HIV prevalence by age and sexHarare 2002 10+ 5+

31. Age-Difference Paradigm Implications for AIDS prevention: • men could marry women closer to own age • promote more egalitarian long-term relationships • reformulate power dynamics in intimate relationships • expanded notions of women’s rights and equality • how women negotiate safe sex across generational divides

32. Power Paradigm • gendered power dynamics lurking in all of this • gender and power often discussed in relation to • men’s violence against women • importance of also recognizing how gendered • power relations shape intimate relationships • in more subtle ways as well

33. Current Research in Bwaise How are changing conceptions of masculinity affecting power relations within couples in urban Uganda? How interventions focused on reducing HIV transmission within couples can address gendered power dynamics in all their social complexity.

35. Stephen Lewis Former UN Special Envoy for HIV/AIDS in Africa Closing Session of the XVI International AIDS Conference Toronto, Canada 2006 The most vexing and intolerable dimension of the pandemic is what is happening to women. It’s the one area of HIV/AIDS which leaves me feeling most helpless and most enraged. Gender inequality is driving the pandemic, and we will never subdue the gruesome force of AIDS until the rights of women become paramount in the struggle.

36. The Backlash Malcolm Potts, Daniel Halperin, et al. “Reassessing HIV Prevention” Science 2008 In 9 southern African countries, more than 12% of adults are infected with HIV. Such devastating epidemics have frequently been attributed to poverty, limited health services, illiteracy, war, and gender inequality. Although these grave problems demand an effective response in their own right, they do not appear to be the immediate causes of generalized epidemics.

37. The Backlash James Chin The AIDS Pandemic 2007 UNAIDS continues to declare that poverty, gender inequality, discrimination and stigma, and lack of access to healthcare are the major determinants of high HIV prevalence in SSA populations…but they are not the primary are even major determinants of high HIV prevalence.

38. The Backlash Elizabeth Pisani The Wisdom of Whores 2008 The ‘HIV is a development problem’ chorus has become a self-fulfilling prophecy in Africa…The World Bank believes poverty and gender inequality spread AIDS. I believe sex and drug injection spread AIDS.

39. The Backlash Against the Backlash Lancet August 2008 Special Series on the State of the Science of HIV Prevention Combined Prevention: Biomedical, Behavioral, Structural

40. The Backlash Against the Backlash Richard Horton and Pam Das Lancet August 2008 HIV Prevention has overly focused on individual behaviors. The provocative but ultimately flawed arguments of Elizabeth Pisani are one recent and much discussed example. Prevention needs to embrace the political, economic, and social determinants of risk.

41. The Backlash Against the Backlash Chris Collins, Thomas Coates, and James Curran AIDS August 2008 Special Issue on HIV Prevention Absent from the ABCs is an acknowledgement of the limitations of self-determination in this epidemic and the powerful impact of social factors such as stigma, the unequal status of women and girls, poverty, laws criminalizing drug use and anti-gay bias.

42. The Backlash Against the Backlash Alan Greig, Dean Peacock, Rachel Jewkes et al. AIDS August 2008 Special Issue on HIV Prevention The imperative of addressing the gender dimensions of AIDS has been clearly and repeatedly articulated…We can no longer simply pay lip service to the urgent need to act on what we know about gender and AIDS. Simply put, it is time to act.

46. HIV Prevalence in Ugandan Couples Some Evidence Married Couples Account for Largest Proportion of New HIV Infections in Uganda