Background: Despite dramatic improvements in access to antiretroviral treatment (ART) in sub-Saharan Africa, men are less likely than women to test for HIV and to link to ART when they test positive. This poses an important challenge to the attainment of the 90-90-90 targets.
Methods: We explored HIV+ men''s challenges to HIV testing and care at three purposively-selected high-volume ART clinics in rural Zimbabwe. We conducted twenty focus group discussions with 57 HIV+ men in Community Antiretroviral Refill Groups (CARGs), 61 HIV+ men not in CARGs and 29 HIV+ women in CARGs, and 46 in-depth interviews with policy makers, implementers, community members and health care workers. Data were analyzed using deductive and inductive approaches.
Results: Masculinities and concerns about social status?expressed through the idioms of “shame”, “fear” and “pride”?were prominent themes for why few men get tested for HIV or initiate ART. Men were “ashamed” to be seen testing for HIV by community and family members because it implied “promiscuity”, whereas collecting medications at health facilities (HF) publicly revealed one´s HIV status. HIV testing and HIV care were thus seen as potentially damaging to men´s reputations. “Fear” of marital conflict was another barrier as wives accused husbands who tested HIV+ of infidelity. Consequently, many men preferred to wait for wives to get tested first or for wives to suggest testing together. The last idiom?men´s “pride” - is deeply tied to notions of masculinities. Men believed they were invincible, and thus downplayed the importance of getting tested, denied an HIV+ result, refused to initiate ART, or stopped taking medications when their health improved or they started new relationships. Other men avoided HIV testing because they did not want to use condoms with wives if found positive, while others did not want an HIV+ diagnosis to affect their ability to attract new sexual partners. Some men considered HF to be “female spaces” and did not want to be seen there. Finally, only economically unproductive men were believed to spend hours at HF.
Conclusions: Men''s needs and lived realities continue to be a “blind spot” in HIV programming (UNAIDS 2017). Innovative men-focused strategies are urgently needed.