Addressing Gender Dynamics and Engaging Men in HIV Programs: Lessons Learned from Horizons Research

"In the field of human immunodeficiency virus (HIV) prevention, there has been increasing interest in the role that gender plays in HIV and violence risk, and in successfully engaging men in the response."

From Public Health Reports, March-April 2010, Volume 125, "[t]his article highlights findings from more than 10 studies in Asia, Africa, and Latin America - conducted from 1997 through 2007 as part of the Horizons program - that have contributed to understanding the relationship between gender and men’s behaviors, developing useful measurement tools for gender norms, and designing and evaluating the impact of gender-focused program strategies. Studies showed significant associations between support for inequitable norms and risk, such as more partner violence and less condom use. Programmatic lessons learned ranged from insights into appropriate media messages, to strategies to engage men in critically reflecting upon gender inequality, to the qualities of successful program facilitators. The portfolio of work reveals the potential and importance of directly addressing gender dynamics in HIV- and violence-prevention programs for both men and women."

Figure 1 shows a summary of horizon studies. Intervention strategies that Horizons and partners developed and evaluated include [Footnotes removed by editor]:

• Engage men in thinking critically about gender inequality - "In Brazil, researchers investigated the impacts of interactive group education sessions for young men and a community-wide “lifestyle” social marketing campaign that used gender-equitable messages to promote safer sex and healthier relationships - called Program H (for men, or homens in Portuguese).  Activities in the group education sessions included role-plays, brainstorming exercises, discussions, and individual reflection, led by adult male facilitators. Both the group sessions and the social marketing campaign aimed to promote critical thought on gender norms by encouraging young men to reflect on how they act as men, while also enjoining them to respect their partners, avoid using violence against women, and practice safer sex....Qualitative data from intervention participants demonstrate the effectiveness of helping young men actively reflect on the ways that gender inequality plays out in their own lives....Quantitative data also show the effectiveness of engaging men to reflect critically on their roles and relationships."
• Focus interventions on younger men - "Horizons studies highlight the feasibility and effectiveness of focusing interventions to change gender norms on young men as they are starting to develop intimate romantic and sexual relationships for the first time.
• Include interactive, small-group sessions and community-based activities - "In both Brazil and India, small-group sessions used interactive exercises to cover such topics as gender and sexuality; STI/HIV risk and prevention; partner, family, and community violence; the reproductive system; alcohol and risk; and HIV-related stigma and discrimination."
• Use the media to promote gender equity and HIV prevention - "In Nicaragua, Horizons and partners evaluated a communication-for-social-change strategy targeting young people that encouraged responsible sex, open communication about sensitive topics, condom use, and empowerment of women...." The intervention included a television soap opera series, a youth-directed radio show, and various community-based activities (e.g., youth camps). "After following a representative cohort of 3,099 young people aged 13 to 24 from three large cities over two years, the researchers found that overall support for gender-equitable norms increased over time. But individuals with the highest level of exposure to the intervention became significantly more 'gender equitable' compared with those with lower levels of exposure.”
• Reach men directly when their partners are pregnant - "In an intervention in Kenya, program staff talked about PMTCT [prevention of mother to child transmission] of HIV with men rather than through women, inviting men to the clinic for HIV testing, community education on PMTCT in places where men congregate, and support groups for men. These strategies led to significant increases in HIV-related discussions between female clients and their regular partners, HIV testing of male partners of PMTCT clients, and disclosure of HIV results by both women and men to a regular partner. A Horizons study in Zimbabwe also explored whether promoting male involvement in their partners’ pregnancy and in antenatal care would result in couples practicing HIV/STI protective behaviours. The intervention included community outreach, male-oriented educational materials, a group talk to antenatal clinic clients, and couples counseling by nurse midwives. Of all the intervention components, outreach activities showed the most promise, successfully promoting community discussions and personal reflection about male involvement and sexual health. Community health workers conducted the outreach activities, which included such interactive strategies as picture cards, role-playing, posters, and flash cards. Couples counseling was the weakest component of the intervention, due to counselor attrition, limited participation by male partners, and the difficulty of counseling on sensitive topics."

In order to study gender equity uniformly in its programmes, Horizons researchers "developed and validated the Gender Equitable Men (GEM) Scale. This scale includes items on women’s and men’s roles in domestic work and child care, sexuality and sexual relationships, reproductive health and disease prevention, violence, and homophobia and relations between men. Items were based on previous qualitative work and a literature review, and initially administered to a household sample of 742 men aged 15 to 59 years in Rio de Janeiro, Brazil. ...Figure 2 displays examples of items from the original 24-item GEM Scale developed in Brazil and from subsequent adaptations of the scale for India and Ethiopia.”

The document concludes with the recommendation that a long-term strategy be engaged with a variety of approaches: "it is important to build programs that support long-term, sustained change in gender norms by fostering broad-based, ongoing discussion on manhood, masculinity, and gender dynamics."