احترام مردسالاری و شهرت: چگونه مردسالاری جذب درمان مردان HIV در مناطق روستایی شرق اوگاندا را تحت تاثیر قرار می دهد

Abstract 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.

Introduction 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). Men's under-utilisation of HIV/AIDS treatment in high prevalence settings contrasts starkly with initial fears that they would disproportionately access treatment compared to women (Pirkle, Nguyen, Ag Aboubacrine, Cissé, & Zunzunegui, 2011), and also contrasts with men's greater access to nearly all resources due to their more powerful patriarchal position in society (Greig, Kimmel, & Lang, 2000). Men's failure to access treatment means a significant care and economic burden to the health system and their families, as well as increased chances of onward HIV transmission to partners (Mills, Beyrer, Birungi, & Dybul, 2012; Peacock et al., 2008). This is a critical policy concern, and highlights the urgent need to identify the underlying factors, in order to modify them to improve men's use of health services (Hirsch, 2007). The majority of the above studies from Uganda and elsewhere in SSA have only described the categorical gender differences in access to treatment, without detailing how norms associated with masculinity may constrain or facilitate men's HIV treatment seeking. There are, however, some important exceptions, from northern and southern Africa e.g., Bila and Egrot (2009), Fitzgerald, Collumbien, and Hosegood (2010) and Skovdal et al. (2011). These studies suggest that there is often a contradiction between men's understandings of masculinity and the biomedical representations of a good patient, undermining their use of HIV services. In urban central Uganda, living with HIV threatens the embodiment of notions of masculinity such as the ability to have sex, have children, earn money and provide for one's family, and the resulting stigma undermines testing (Wyrod, 2011). But these kinds of analyses are just emerging in SSA, and there is insufficient understanding of how the different dimensions of masculinity affect men's HIV treatment seeking behaviour, especially those that encourage it. Framing the discussion around Helle-Valle's (2004) notion of ‘contextualised dividuality’, and Wilson's (1969) model distinguishing ‘respectability’ and ‘reputation’, this article contributes to the literature by examining men's construction of masculinity and its influence on treatment seeking for HIV in Mam-Kiror village in Busia district, rural eastern Uganda. Mam-Kiror is a pseudonym.

Conclusion and implications for public health 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). We found that individual men can engage in a variety of treatment seeking behaviours that typically correspond with different masculine ideologies and dividualities; some discouraging HIV treatment, others encouraging it. On the one hand, HIV treatment may be undertaken and adhered to in order to regain and maintain health, so as to fulfil family and social expectations, notably being a provider and role model. On the other hand, the expression of masculinity through hard physical work, income generation and sexual achievement may compromise men's uptake of HIV testing and treatment since the demands and restrictions associated with ART tend to conflict with these norms of reputational masculinity. These findings have some implications for public health interventions. Programmes that seek to encourage testing and treatment need to be more attentive to the values associated with reputational and respectable masculinities and how each affects uptake of HIV treatment. For example, ART could be promoted by emphasising its value in rebuilding a man's respectability and role as head of family. Men could also be encouraged to go to test with colleagues, and they need to be supported with livelihood projects since it can help them provide for their families and encourage them to maintain HIV treatment. Our findings raise important doubts about the suitability of couple testing.