Social constructions of masculinity
To understand how masculinity interferes with women's ART adherence, this sub-section gives detail on how hegemonic notions of masculinity influence men's experiences of HIV. Both male and female nurses and ARV users made reference to hegemonic notions of masculinity, describing "a real man" as physically strong, tough and resilient to illness, independent, responsible and successful in sustaining his family. For a man to contract HIV and develop AIDS is therefore perceived as a threat to his sense of masculinity:
I really felt such HIV tests were going to embarrass me and make me feel useless. As a man I have that pride of being the father, the husband and head of the family and can you imagine an HIV positive result will just wash away all that respect. (Joseph, patient)
There is that pride and men feel that being ill is a women's issue because it is rather belittling to be seen coming to the hospital every now and then as it is a sign of weakness. (Philip, patient)
The idea that being ill belittles a man's sense of manhood and role as head of household and that hospitals are seen as female territories highlights the conflict that exists between socially constructed notions of masculinity and HIV.
Men's fear and denial of HIV
To mediate the links between social constructions of masculinity and husbands' interference with their wives' ART adherence, we now turn to examining the conflict that exists between masculinity and HIV and how this has led many men in this context to develop a profound fear of any association with HIV, preventing them from getting tested and disclosing their HIV status:
There are people in this community who are not feeling well and know that they should go and get tested for HIV, yet they are afraid to ... The problem is very common with men, men are afraid to come out in the open and face the reality. (Henry, patient)
In giving detail to their fear of HIV and AIDS, male participants spoke about some of the consequences of testing HIV positive to their manhood. For example, men reported that that testing positive would represent them as promiscuous and irresponsible:
For me, it kind of gives people an impression that I have been sleeping around carelessly, which is not true at all. We have been given information that this disease mainly affects people who sleep around carelessly, and, when one tests HIV positive, it kind of confirms to the public that I have been having careless extra-marital sexual relationships. I was really worried, and I couldn't come to terms with an HIV positive result. (Liyod, patient)
Such representation, coupled with their HIV status, made married men fear that their wives would leave them, while younger men felt that women would have no interest in them and that they would remain bachelors for the rest of their lives:
If positive, some young men feel they would lose their chances of getting a woman to marry them. (Henry, patient)
Nurses and ARV users of both genders articulated the pressure that men are under to conform to hegemonic notions of masculinity and their fear of the potential consequences of being HIV positive. As illustrated by Henry, this can lead men to deny the fact that they may be HIV positive and delay seeking HIV testing and treatment. The men participating in this study spoke about their difficulties in coming to terms with their HIV status and admitted that it was only when they were very ill and had developed AIDS that they got tested and enrolled onto ART. Not only does the profound fear that is embedded in men's experience of HIV impact negatively on men's own health, it can also, as we will now discuss, interfere with women's treatment of HIV.
Masculinity interfering with married women's ART adherence
While women in this context were good at making use of HIV services, they faced a number of obstacles in their efforts to adhere to ART, many of which related to their husbands' fear of association with HIV. Women who had gone to get tested and tested positive and knew of their husbands' fear of HIV were often afraid of telling their husbands about their HIV seroconversion:
I know a certain lady who attended these HIV/AIDS functions and decided to take up HIV tests and she tested HIV positive, but she could not tell her husband even though she suspected him of being the one who infected her. (Constantine, patient)
Women unable to share with their husbands their HIV status and their need to comply with a strict treatment programme miss out on getting support from family members, compromising their ability to adhere successfully.
Men's non-disclosure of their HIV status, as well as their position in deciding whether or not to use condoms when having sex with their wives, can leave women open for infection or re-infection, particularly if their husbands are not on ART [
30]. A number of women on ART spoke about their husbands' denial of their HIV status and their continued promiscuity, fearing re-infections that might complicate their treatment regimen:
Men are a problem. Women on ART come to support group activities, yet their husbands do not come and we don't know whether these men have been tested. In these support groups, we are taught to have protected sex to avoid re-infection, but the husbands do not come. If I am on ART but my husband is still unwilling to get tested for HIV, he will refuse to have protected sex, yet I am already on ART and at risk of being re-infected. (Martha, patient)
A number of nurses, when speaking about challenges to women's adherence to ART, recognised the role of their clients' husbands and often felt demotivated by their efforts to support women on ART as their advice to female patients was often undermined by their patient's husbands:
I am very unsatisfied and I feel pulled down when I am dealing with a female patient whose male counterpart refuses to come for [an] HIV test. You see this means your efforts are in vain because you treat her and she goes to be re-infected at home because the husband disregards condom use. (Roselyn, nurse)
Rooted in men's fear of association with HIV, nurses frequently spoke about how husbands could prevent their wives from attending monthly review dates and picking up their antiretroviral drugs - interfering with women's adherence to ART. Some men were reported to have stolen their wives' hospital cards in an attempt to prevent them from going to the clinic:
Some women say their husbands deny them the right to come to the hospital saying "you want to expose me that I am HIV positive", so they even go further by stealing their wives' hospital cards. However, such husbands need counselling. (Tsitsi, nurse)
Another commonly reported strategy used by husbands to disassociate themselves with AIDS and prevent their wives from going to the hospital and adhering to their treatment was to threaten their wives with divorce if they continued to make use of HIV services:
Women when they come to get services from the opportunistic infection (OI) clinic and they are initiated on ART, the husband will then threaten to divorce the wife if she continues taking antiretroviral drugs. This will then affect her ability to adhere to ART. (Weston, nurse)
Finally, and reflecting men's own fear of enrolling onto an ART programme, husbands were reported to steal ARVs from their wives to take themselves:
... as you ask into why she did not adhere she will begin to open up and she may even cry telling you the real problem; "I have a problem, my husband doesn't want to come to OI clinic, when I get my monthly supply, he will grab my tablets and take them himself." (Weston, nurse)
In this subsection, we have outlined some of the many varied ways through which men's fear of HIV and AIDS, rooted in hegemonic notions of masculinity, can prevent their wives from adhering successfully to ART.