Men Hold the Keys: Negotiating the influence of men on women who need oral PrEP
By Alfred Itunga, Technical Communications Officer, LVCT Health Scientific evidence shows that daily oral PrEP can reduce the risk of HIV when taken consistently and correctly. But the advances of science are not enough. Any intervention, no matter how well it works in a clinical setting, will work differently in the real world.
In Kenya, the young women who enrolled in an oral PrEP project needed approval from the men in their lives before they could take oral PrEP. Kenya’s patriarchal society gives men power over many aspects of a woman’s life, including her healthcare. At LVCT Health’s PrEP project, Introducing PrEP into HIV Combination Prevention (IPCP), many husbands or boyfriends simply said ‘no’. Women in the program said male reaction can even be violent. In response, some women hid pills, some skipped doses, others just didn’t take it at all. One participant looked forward to a time when her husband would support her.
“My husband does not know, that is my secret. I find it difficult because he has not understood what PrEP is. So, with time I will find a way of convincing him in order to make him understand what PrEP is.”
The attitude of men in the community stood in the way of many women who might otherwise use oral PrEP, so staff at LVCT Health prepared an informational campaign designed to reach and engage these husbands and partners.
We decided to profile men... we really wanted to know who these men were, what do they do, where do they stay. After profiling, we learnt that most of the men are either artisans or boda boda riders. So we opted to speak to these men and the best way to speak to these men was during their social welfare group [meetings] and Chief Barazas [community] meetings.” —Maryanne Ajwang, clinical nurse at LVCT Health
Because men would need to hear from fellow men, LVCT made sure to send a male staff member to lead presentations introducing IPCP, explaining oral PrEP and how it could prevent more HIV infections and related deaths in their communities.
This approach convinced some to let their sexual partners enroll in the project and take the daily pill. Some even became “PrEP buddies” and would accompany their female partners to the clinic and help them remember their daily dose. One husband told clinic staff, “You know, if I die of HIV, the only person who can take care of my children is my wife, so my wife needs to be healthy to be able to take care of my children.”
However, others remained adamant. They refused to accept oral PrEP, and tied the protection it offers from HIV to promiscuity. One man told staff, “My wife cannot take those pills. She cannot take them.” His wife later said he had returned home, found the pill bottle and set it on fire.
Among those men who accepted oral PrEP, their partners expressed a greater empowerment. They felt encouraged to continue PrEP, brought their partners for testing, and sought more education on oral PrEP and other prevention methods including condoms.
As countries roll out oral PrEP, the opinion of men and their attitude toward oral PrEP will often determine if women take oral PrEP. Roll out should include ongoing engagement with men from the onset of a program. With the support of men in the community, PrEP uptake will be higher, cases of gender-based violence will be fewer, and new HIV infections will go down.
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There’s no question that a simple regimen of a single daily pill can slash HIV infections in people at risk. But although millions of people around the world could benefit, only 200,000 are prescribed PrEP, and 75 percent of them are in the United States. The disparity was the focus of anguished discussions this week at the largest annual US HIV/AIDS conference.
The Center for AIDS Research at Emory University's Rollins School of Public Health produces interactive online maps with visualized data on different aspects of the US HIV epidemic, and its prevention and treatment response, at AIDSVu.org. This set of maps and statistics focuses on PrEP use nationally and by state from 2012-2016.
The International Treatment Preparedness Coalition (ITPC) has released the Key Population Activist Toolkit on PrEP, developed to equip community activists to demand pre-exposure prophylaxis (PrEP). The toolkit includes step by step guidance for activists to develop an advocacy agenda to bring effective PrEP programs to their communities.