Toronto I-II 1:00 pm The invisibility of heterosexual men in HIV pandemics

1. Toronto I-II 1:00 pm The invisibility of heterosexual men in HIV pandemics Lesley DoyalEmeritus Professor of Health and Social Care at the School for Policy Studies, University of Bristol, Doyal completed six years as a Visiting Professor at the University of Cape Town Moderator: Winston HusbandsDirector of Research and Program Development at the AIDS Committee of Toronto and a co-chair of the African and Caribbean Council on HIV/AIDS in Ontario

2. Heterosexual men in the HIV pandemic Lesley Doyal

3. Paradox of invisibility • Hetero men often blamed for pandemic but remain in the shadows • No data on numbers infected in different settings • Few studies of experiences of sex, health and health care among men identified/identifying themselves as heterosexual • Most policies designed to meet needs of others not hetero men themselves

4. What do we mean by ‘heterosexual’ men • Usually defined as men who have sex with women • But may not be sexually active at all or may also have sex with other men • So binary categories of ‘gay’ and ‘straight’ or homosexual v heterosexual problematic • Makes counting numbers of HIV+ hetero men and assessment of their needs especially difficult

5. What DO we know about HIV+ hetero men? • Globally 60% of HIV positive people are women • So remaining 40% are male but their sexual practices/identities not known • North America majority of these are MSM but more likely to be hetero/MSW in African region • In most settings hetero men less likely than hetero women or MSM to access ARV’s and more likely to die while being treated

6. Explaining patterns of risk : sex or gender? • Evidence suggests men biologically less vulnerable than women in context of vaginal sex • But socially constructed gender (masculinity) seems to be a key factor in increasing male risk as well as limiting access to care once infected

7. Gender and ‘hegemonic masculinity’ (Connell 2005) • Men expected to be physically strong and not to show weakness • Assumed to be sexually ‘needy’ with ‘natural’ desire for multiple female partners • Allocated emotional and physical dominance in intimate relationships with women, • More likely than women to smoke and to drink to excess and to be injecting drug users • Expected to be breadwinners for families.

8. How is this linked to HIVHow has this been linked to HIV prevention and to care? • Hetero men choose to engage in more unsafe sex than hetero women • Health care system avoided as ‘female’ or ‘gay’ space associated with weakness • Leads to later testing, poorer diagnosis, less adherence to treatment and greater likelihood of early death (Mills et al 2012; Cornell et al 2011) • So ‘hegemonic masculinity’ can affect both sexual and health related behaviour in negative ways • Still basic lens though which hetero men are viewed in context of both prevention and treatment

9. But what are the problems with this approach? • Does have value in some settings but models of masculinity vary over space and time • Many men unwilling to ‘perform’ masculinity in this way and actively choose alternatives • Some live in settings where living up to these expectations not possible • Individuals respond differently to these circumstances : may adopt ‘hypermasculine’ approach as backlash or move towards more egalitarian gender relations • So masculine attitudes and behaviour not innate but socially constructed in context of different communities and relationships

10. Model of het masc leaves out major areas of +ive men’s lives • Fatherhood: little attention paid to men’s desires re parenting which may be very strong • Work: very few studies of impact of loss of physical strength and earning capacity in diminishing sense of ‘manhood’, loss of respect and identity • Sex : subjective experience of HIV diagnosis on sex life after diagnosis largely ignored (may be especially important in discordant couples)

11. Positive men speak out • Work : ‘I worry a lot and I cannot sleep...I cannot find an income. I worry about support to family members. To think about these things gives me chest pain and the heart ..it feels like someone stabs me in the heart (Namibia) • Sex: ‘...you have nothing to eat in the house or a glass of wine for your wife. So you go in the bed bad you’re fearing to touch her. You can’t say can you turn this way? (LAUGHTER) No definitely you can’t!. (Ugandan migrant in London) • Fatherhood: ‘Well as a man, you know you want to have a family....if you don’t the elders in that clan or in that extended family begin to say something like ‘you’re useless, you’re worthless...’(another Ugandan migrant in London)

12. Intersectionality and masculinities • So heterosexual men not homogeneous group • Diversity takes many different forms which interact with each other to shape vulnerability to HIV as well as quality of care received • Socio-economic status, race/ethnicity, patterns of drug use, age all of central importance as is geo-political status • But interrelationships complex and vary by settings

13. For example..... • US: high (and increasing) rates of HIV morbidity and mortality in (heterosexual) subgroup of African/Americans and African migrants attributed to combination of oppression, stigma, racism and poverty. So deprived minority in rich country • African region: black men in majority rather than being a subgroup and wealthier men often at greater risk than poor though likely to get better care. But all living in low or middle income countries with few resources for prevention or care

14. Implications/questions for research and policy • Vital to explore models of masculinity shaping identities of men in specific settings • Also need to be aware of the many structural factors placing constraints on options of men identifying or wishing to be identified as heterosexual • Is it feasible to target ‘heterosexual men’ as a group or should the focus be on specific subgroups of MSW such as IDU’s? • And finally.....how do we reconcile the needs of heterosexual men with those of heterosexual women in context of both prevention and treatment across a range of settings ?

15. What’s next? • 2:30 pmBreak/Networking/Poster Sessions • (Foyer) • 2:30 pmVisual Story Galleries • (Foyer, Richmond, University, Adelaide)