After more than thirty years of combating HIV (human immunodeficiency virus) and despite progress in both treatment and reducing the stigmatization of people living with HIV (PLHIV), issues related to the epidemic persist. The HIV epidemic is still a problem everywhere in the world, but particularly in developing countries, where numerous barriers continue to limit access to information, prevention, and treatment.

The Joint United Nations Program on HIV and AIDS (UNAIDS) has set an ambitious goal of eradicating HIV as a public health threat by 2030, and an intermediate goal known as “90-90-90” (90% of HIV-positive people knowing their status, 90% of HIV-positive patients under treatment, and 90% of treated patients having an undetectable viral load) by 2020 (1) (2).

Sub-Saharan Africa bears the heaviest burden of this epidemic, with 25 million people affected (it accounted for 66% of the world’s HIV-positive population in 2015) and 1,300,000 new cases in 2015 (3). This is a very different situation than in the global North, where the incidence is far lower and mortality well-controlled. And while there has been undeniable progress on all continents with ever-increasing numbers of PLHIV on antiretroviral therapy (ART) – especially in sub-Saharan Africa, where 11 million people now have access to ART – the epidemic is clearly still active.

A number of factors in sub-Saharan Africa hinder access to the kind of HIV care offered in the global North. These include difficulties accessing the latest generation drugs, which are still too expensive; dependence on international AIDS agencies for human, physical, and economic resources; and other humanitarian situations that sometimes complicate public health management of HIV (4).

This is the reality in Nyanza Province, a rural area in western Kenya where this study was conducted. The prevalence in this region of 4.4 million inhabitants is an estimated 15%, and in some districts is as high as 25%. The mortality rate is also very high, due to AIDS (Acquired Immune Deficiency Syndrome) in particular (5).

MSF (MSF Médecins Sans Frontières) has been working in this region for nearly 20 years trying to reduce the epidemic’s impact. Thanks to MSF, several thousand people have started on ART despite institutional, structural, human, and technical obstacles. Access to care is still inadequate for all segments of the population. Testing, access to care, and treatment adherence are currently well 14 below the UNAIDS 90-90-90 objectives (6). The male population is least likely to be tested in testing campaigns; it has poorer treatment adherence and a higher mortality rate.

In Nyanza, where gender relationships and societal functioning have their roots in a specific history and sociology, few studies have examined access to testing and the determinants of treatment adherence for the male population.

In a high-prevalence area, behavior change is often spurred by an individual’s awareness of the risk of infection, by testing, and by learning that he is HIV-positive. In particular, such change is reflected in the relationship between the sexes and in the demand for care. The individual then weighs the HIV-related risks against a whole set of health, social, and economic considerations. Hence there may be some process by which the risks and benefits of given behaviors are prioritized.

It appears as though health care interventions need to take these issues into account if they wish to integrate some individuals into a health care effort. Yet few interventions specifically target aspects of male life, such as sexuality and parenthood, for example. Moreover, “masculine” behaviors have recently been used to explain the high HIV transmission rate in this region – hence, men are being blamed (7).

At a time when there seems to be a great deal of pressure on the individual and societies to achieve the global objective of HIV eradication, it would seem important to include and support every individual in the health care effort and process. As we will see, simply setting up a testing or care campaign does not necessarily mean that the entire population will participate; the message has to be tailored to the target population and fine-tuned even within that population.

Read more : Chapter 1