Johannesburg — As we enter the third decade of the HIV/AIDS epidemic, prevention efforts have yet to come to grips with a deep-seated antipathy to condoms, particularly in southern Africa, the region worst affected by the crisis.
Much has been said and written about the myths and misconceptions inhibiting condom use, but little has been done to reflect these realities in existing HIV/AIDS awareness and prevention campaigns.
According to Amy Kaler, a sociologist who conducted research into men and behaviour change in Malawi, researchers have yet to move beyond making generalised sweeping statements "about African men hating condoms".
In the study, conducted as part of the Malawi Diffusion and Ideational Change Project (MDICP) in the rural south of the country, men identified three forms of behaviour change: being more selective about their sexual partners; reducing the number of partners; and using condoms.
CLOUD HANGS OVER CONDOMS
The least popular form of behaviour change reported by the study was the use of condoms.
"Condoms were disparaged on many grounds: they were un-aesthetic and deprived both men and women of pleasure in sex; they were an insult to one's female partner because of their connotations of disease and adultery; they were ineffective against AIDS, or they were actually tainted with the virus or a cancer-causing agent, as part of the Malawian government or some unnamed international cabal's efforts to wipe out the population," the report noted.
Kaler warned that prevention campaigns could not dismiss these objections - particularly the notion that the prophylactics were a form of population control.
In a separate report taking a closer look at these findings, Kaler pointed out that interventions like condom promotion and distribution had been undermined by suspicions that the Malawian government and international donors were using HIV/AIDS as part of a population control conspiracy.
"Everyone knows that he/she is infected and we shall all die because the government has spread AIDS in many ways, such as condoms, injections, family planning methods, transfusions and many more," a study participant was reported as saying.
Kaler told PlusNews that these findings were not restricted to Malawi and were also common in countries like Zimbabwe and South Africa, where Africans had been subjected to white minority rule.
Given the historical and political context, it was clear that these misconceptions had to be confronted. "These views should not just be seen as crazy talk," she stressed.
In Swaziland, the country with the highest HIV prevalence figures in the world, condoms are the most readily available free commodity - they spill out of public bathroom dispensers and bowls on the counters of business and government office reception rooms - but, despite surveys showing awareness of how HIV is contracted, condom use remains unpopular among Swazis.
A new AIDS public awareness campaign involving government, health NGOs and faith-based organisations does not even mention condoms, and instead stresses abstinence and monogamy as ways of avoiding HIV/AIDS.
"We have to move on from condoms - that emphasis didn't work," said Nana Mdluli, public relations officer at the National Emergency Council on HIV/AIDS (NERCHA).
Churches and traditional leaders, which wield huge influence in Swazi life, have stood firm against condom usage since the AIDS crisis began. The conservative nation's top traditional leader, Jim Gama, and Nhlavana Maseko, who heads the Traditional Healers Organisation, have both condemned condoms as "unSwazi".
The Catholic Church has never compromised its stance against birth control, and other religious denominations have not pushed the use of prophylaxis either.
"Condoms never caught on - the churches and traditionalists won the battle, but at what cost? They may have lost the war," said a health official who asked not to be named.
"The human toll in lost lives, AIDS orphans, the economic cost - these have been very great. The country has one of the highest HIV prevalence rates in the world. Even with ARVs, a quarter of the population will die prematurely - a small and poor country can't afford that. People may look back and see that a little latex condom could have meant national survival," he commented.
Part of the problem relates to the difficulty of understanding transmission of the infection. Because an HIV-positive person can live a long and healthy life before the infection becomes apparent, and not all exposures to HIV lead to transmission, the link between using condoms now and not having AIDS a few years down the line is hard to prove.
According to Kaler's report, "Because the efficacy of condoms is hard to establish by observation, using condoms to prevent HIV transmission is, in some measure, a leap of faith and an expression of trust in the goodwill and wisdom of those people who promote condom use as a way to stay healthy. In Malawi, as elsewhere, this leap can be difficult to make."
NOTIONS OF MASCULINITY
Taking a blind leap of faith is even harder when faced with cultural and psychological mechanisms that make risk-taking attractive - not just in Africa, but also in other parts of the world.
For example, masculine norms based on valorising risks and the notion that "real men take on danger" could also be applied to sexual behaviour.
In a book based on the evaluation of a pilot project in community-based prevention in a South African mining town, 'Letting them die: How HIV/AIDS prevention programmes often fail', researcher Catherine Campbell found that the notion of masculinity played a key role among mineworkers, helping them cope with the demands of the work and overcome their daily fears of injury and death.
"Ironically, the very sense of masculinity that assists men in their day-to-day coping also serves to heighten their exposure to the risks of HIV infection," Campbell observed, because a need for multiple partners and the desire for flesh-to-flesh sexual contact were closely linked to this masculine identity.
Another reason for the desire for "flesh-to-flesh" sex among mineworkers was the "broader social context of general loneliness and reduced opportunities for intimate social relationships", as sex without a condom often symbolised a form of emotional intimacy, according to the author.
The mineworkers participating in the study also made a strong connection between sex and masculinity in relation to their physical and mental health.
In Malawi, Kaler noted that "skin-to-skin ejaculation is the marker of a real man - one who uses condoms is being cheated out of his right to a high-grade sexual experience, or may even be the subject of gossip or ridicule".
Prevention messages emphasising safe behaviour and not taking chances did not resonate with masculine sub-cultures, she pointed out. "Playing safe is not really what you want to do as a young man," which needed to be taken on board when designing interventions.
"People know what AIDS is, how you get it ... what is necessary [now] is making it seem possible to act on this information ... people have to believe a difference can be made, and their agency can make a difference," Kaler commented.
The claim made by many men that they were already infected with HIV, making it futile for them to change their behaviour was "a particularly intriguing finding", said the report.
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This was rhetorical because virtually all the men who made this claim had no way of determining their status, as HIV tests were not easily available in rural areas, and few men would travel to urban hospitals to be tested.
HALF A STEP FORWARD
With condoms still the least popular form of behaviour change, the MDICP study found that men's preferred approach to risk mitigation was old-fashioned "biographical criteria" - a woman's family tree and her comportment.
Women were described as being desirable partners on the basis of their social position or personality: women and girls who came from "good" families were preferred, and perceived as less likely to have HIV/AIDS.
Schoolgirls were considered desirable partners, as they were likely to have had few previous partners.
However, character was seen as a more reliable criterion for selecting AIDS-free partners. Women who were known to have rejected the advances of other men, and viewed as "controlled" or "proud" gained value in the sexual marketplace, the report noted.
Admittedly this form of behaviour change was the least effective, Kaler told PlusNews and was "more of a half-step forward" in terms of HIV prevention.
Overcoming these half-measures is the challenge, and one that education campaigns seem reluctant to tackle, not realising that prevention messages are forced to compete with alternative beliefs, and ideas about health, danger and self-protection that can be more powerful than the information they are trying to disseminate.
[ This report does not necessarily reflect the views of the United Nations ]
