There is increasing evidence in SSA that once infected with HIV men are disadvantaged compared to women in terms of uptake of treatment. In Uganda fewer men are on treatment, they tend to initiate treatment later, are difficult to retain on treatment and have a higher mortality while on treatment. This article discusses how men's response to HIV infection relates to their masculinity. We conducted participant observation and in-depth interviews with 26 men from a rural setting in eastern Uganda, in 2009–2010. They comprised men receiving HIV treatment, who had dropped treatment or did not seek it despite testing HIV positive, who had not tested but suspected infection, and those with other symptoms unrelated to HIV. Thematic analysis identified recurrent themes and variations across the data. Men drew from a range of norms to fulfil the social and individual expectations of being sufficiently masculine. The study argues that there are essentially two forms of masculinity in Mam-Kiror, one based on reputation and the other on respectability, with some ideals shared by both. Respectability was endorsed by ‘the wider society’, while reputation was endorsed almost entirely by men. Men's treatment seeking behaviours corresponded with different masculine ideologies. Family and societal expectations to be a family provider and respectable role model encouraged treatment, to regain and maintain health. However, reputational concern with strength and the capacity for hard physical work, income generation and sexual achievement discouraged uptake of HIV testing and treatment since it meant acknowledging weakness and an ‘HIV patient’ identity. Men's ‘dividuality’ allowed them to express different masculinities in different social contexts. We conclude that characteristics associated with respectable masculinity tend to encourage men's uptake of HIV treatment while those associated with reputational masculinity tend to undermine it.
Gender equality in access to HIV treatment in high prevalence settings, particularly sub-Saharan Africa (SSA), has attracted significant interest in recent years. Although women in most parts of SSA, and Uganda in particular, still have a higher prevalence of HIV than men (Ministry of Health (MoH) Uganda, ICF International, Calverton Maryland USA, Centers for Disease Control and Prevention Entebbe Uganda, Uganda, U. S. A. f. I. D. K., & WHO Kampala Uganda, 2012; UNAIDS, 2010), there is growing evidence that, once infected, men are more disadvantaged in terms of access to HIV treatment compared to women (Amuron et al., 2007; Birungi & Mills, 2010; Braitstein, Boulle, & Nash, 2008; Muula et al., 2007; Nattrass, 2008). In Uganda, compared to women fewer men are on HIV treatment, they tend to initiate treatment later, are difficult to retain on treatment and have higher mortality on treatment (Alibhai et al., 2010; Kigozi et al., 2009; Lubega et al., 2010; Mermin et al., 2008; Nakigozi et al., 2011).
This is the first study in Uganda to explore how masculinity affects men's uptake of HIV treatment by comparing men who are currently receiving treatment, those who have dropped it, those who refused to initiate it despite testing positive and those who have not tested but believe they are infected. The study shows that irrespective of HIV, men of Mam-Kiror drew from a range of ideals to fulfil the social and individual expectations of being sufficiently masculine. These masculine ideals can be categorised into two main forms of masculinity – respectable and reputational – with some ideals being shared by both. Respectable masculinities are endorsed largely by the wider society, while reputational masculinities are endorsed predominantly by the men themselves. Theoretically, this categorisation is consistent with the distinction between the value systems of respectability and reputation as described by Wilson (1969). Men's ability to adopt, unproblematically, the reputational form of masculinity in one circumstance and the respectable form in another, could be explained using the concept of dividuality, as discussed by Helle-Valle (2004).
