Introduction
Methods
Study design, sampling, data collection and analysis
Results
Participant characteristics
Respondent Groups | Male (n = 68) | Female (n = 4) | Median Age [age range] | Completed Secondary Education | Living with partner |
---|---|---|---|---|---|
Male ART clients -suppressed VL
| 16 | 35 [18–54] | n = 10 | n = 5 | |
Male ART clients - unsuppressed VL
| 23 | 34 [18–53] | n = 13 | n = 13 | |
Male community respondents
a
| 17 | 35 [24–51] | n = 9 | n = 11 | |
Stakeholders
| 12 | 4 | 44 [26–61] | n = 16 | n/a |
aIt emerged during the interviews that four male community respondents were HIV−positive and on ART at local health facilities |
HIV and ART perceptions projected onto PLHIV
When you have gone for drinking, you cannot buy your drink and join those that know you to have HIV as these people get to think that if I stay with this HIV person what will people think about me? Even when playing football, people say that “he does not have energy, that one, do not touch him, he will fall down”. (male community respondent, 26 years).
Stigma intertwined with masculinity considerations
R: When you compare your performance before starting ARVs and after taking ARVs there is really a disturbance and reduction in performance… When you go out with a woman you only realize you have only been able to only have sex with her in one round, it really disappoints because the woman thinks you are a weakling, yet the ARVs are the ones making you weak.
I: Have you yourself ever stopped taking ARVs at some point in time because of the same issue?
R: Yes, I have…It happens that when I have done only one round, I sleep the whole night and I do not even desire to still do more sex. Things like these are really challenges.
I: What year was it when you had opted to skip ARVs because of this?
R: It is generally all the years but now I just came to accept it that this is how things are like now. (male ART client, unsuppressed VL, 29 years)
But somebody who has got a decent job, say for example, like myself, if I was HIV positive for instance, chances are, I would not declare my status…. if I have got a problem I would go, maybe like to a private hospital for instance, I would pay for services so I do not need to say it in the open because to them, somebody who comes out in the open, it’s like you are asking for help. (male stakeholder, Academia, 2)
They are still men, they still maintain some of the characteristics that men are, but their focus in relation to HIV is totally different, it’s still being on treatment and having better health and helping someone out and they don’t care what people say about it. (male stakeholder, NGO, 3)
Men viewed differently throughout the life-course
There is a big difference: older people are mature, so they understand issues better than young people and they are at least committed to ART than younger men. Most young men shun treatment; they are shy, afraid of friends and above all young people lack responsibility. (male ART client, suppressed VL, 45 years)
In our culture, if a man is involved in risky behaviors, it’s a little bit acceptable… for a man it is perceived normal…for younger men, it’s like, no, these people are involved in promiscuous behaviors, that’s why they have HIV” (male stakeholder, NGO, 2).
The community is more of accepting the older men who are living with HIV than the younger ones. The younger ones it’s like the perception is you have already destroyed your life before you have started it. You were promiscuous… For older men, it’s like the situation is accepted to a certain extent…You have lived part of your life, so you can manage the remainder. (male stakeholder, NGO, 3)
I would say it’s very rare for older men, it’s very rare to classify them. Most maybe we say even, if he is sick, no one knows he is taking medication maybe because of the old age (male stakeholder, Church, 1).
From outside to inside perspective: men’s fears and experience of stigma
“My relatives know…but my friends don’t” - men anticipating stigma from outsiders
Even here no one knows that we are on ART; it is only my wife who knows about our status…Even at work, no one was told about my status, and the fact that most of the time, I do come here [to the health facility] on appointment basis, I have always made sure that I plan in time so that it would not collide with my work schedule. (male ART client, suppressed VL, 39)
I stay with my uncle but have never told him that I am HIV-positive. This is because when I sat down and thought about it, I know, that if I tell him there will be discrimination against me and other things. Most people who talk about HIV say that others don’t relate with them well because of discrimination…. We sleep 6 boys in the boy’s quarter, and my uncle sleeps in the main house. So, what happens is that I wake up at 2am and start reading while others are still sleeping so I wake them up at 4 o’clock to get ready and draw water. So when I am going to take a bath is when I get my drugs. I put them in a plastic bag together with a flexa foam [sponge] because they make a noise. Then I put it in my hand like I am washing my face and drinking water. (male ART client, suppressed VL, 18 years)
Fear is there because you think of what your friend’s reaction will be unlike disclosing it to your relatives who understand because you’re a relative but for people you are not related to, they can just abandon you. (male ART client, unsuppressed VL, 18 years)
There’s a clinic in x but I am used to coming here and also for privacy, I don’t want to be seen by people from where I am staying especially my neighbors, but sometimes we still meet neighbors here and then you tend to wonder, “that so, neighbor is here as well”. (male ART client, suppressed VL, 39 years)
They also ask you that why have you made the decision to come and test for HIV…and maybe you have really slept with a girl, and this girl is the daughter of the woman asking you, honestly to us as younger men it makes us uncomfortable because it is our private life. (male community respondent, 24 years)
I think the reason for coming in the evening is hiding, they don’t want other people to know that they are on treatment. If you are suffering from malaria, don’t you come openly? They go to the hospital openly saying I am suffering from malaria. But this HIV, everyone just thinks that they committed a crime, they trampled on thorns, that is what makes people to be coming here in the evening and if you would have been opening at 4 am, you would have seen people coming in larger numbers. (male ART client, unsuppressed VL, 46 years)
Experiencing stigma and MSW’s coping mechanisms
In XX (town) I had problems with the people I was living with close by. They hated me and discriminated me to the extent that I lost hope of life; to them I was as good as a dead person. This prompted me to ask for a transfer from XXX clinic to here. The problem I had was nothing to do with the hospital but where I was staying in XXX. (male ART client, unsuppressed VL, 53 years)
…for me to be fired at X was because I was found HIV-positive… When I got sick, my boss asked me to tell him what it was, so I did. So, he said I don’t want to work with people who are sick, you have to go. (male ART client, unsuppressed VL, 38 years)
Internalized stigma
When I look at someone who is negative and another one who is positive, from my point of view, I regard myself as similar to the one who is negative. I don’t regard myself in any way just because I am taking this medicine. I don’t discriminate myself, by looking at others as normal and that I am not, no. I associate freely with everyone. (male ART client, unsuppressed VL, 39 years)
Older men’s resilience to stigma and wider masculinity repertoire
Most people insult you… As someone who is taking medication, those things don’t bother me… I tell them that it is not everyone who has contracted the disease because of sleeping around with women. Sometimes you just discover you are HIV-positive and you wonder how you got it, because you know you don’t sleep around with women. (male ART client, suppressed VL, 55 years)
Men like me do not care either; they will be discriminated against or not because we are able to make decisions on our own unlike youth, they make decision based on the influence of friends. (male ART client, unsuppressed VL, 53 years)
These youths might be feeling shy when it comes to testing in the communities like here because their fears will be such, such people will see me there. Yes, but for us, the older men we know that it is better to come out openly because maybe our time has gone, we only remain with few days…There is no reason to hide, I have to be getting treatment whether it’s X (facility), whether my children know about it or not, what I know is that I have saved my life. (male community respondent, 48 years)