Running head: MASCULINITY AND HIV Masculinity and HIV Unpacking the relationships between masculinity and HIV in Zimbabwe Student name xxx Supervisors: Professor David Plummer and Ernesta Paukste Griffith University

Running head: MASCULINITY AND HIV Masculinity and HIV Unpacking the relationships between masculinity and HIV in Zimbabwe Student name xxx Supervisors: Professor David Plummer and Ernesta Paukste Griffith University As long as our men are not part of the war, then we should forget about ending HIV/AIDS infection and the violence that comes with it (Musang’u, 2007 HIV World Social Forum) MASCULINITY AND HIV Table of Content ABSTRACT ……………………………………………………………………………………………………………………………………………….. 1-4 INTRODUCTION ………………………………………………………………………………………………………………………………………. 2-6 Purpose ……………………………………………………………………………………………………………………………………………………….. 7 Objectives ……………………………………………………………………………………………………………………………………………………. 7 Masculinity in Zimbabwe …………………………………………………………………………………………………………………………… 8-9 METHODOLOGY ……………………………………………………………………………………………………………………………………… 10 PRISMA ……………………………………………………………………………………………………………………………………………………. 11 STAGE 1 Inclusion criteria ………………………………………………………………………………………………………………………………………… 12 Searching for relevant literature ……………………………………………………………………………………………………………………. 12 Selection of research …………………………………………………………………………………………………………………………………… 12 STAGE 2 Inclusion criteria ………………………………………………………………………………………………………………………………………… 13 Searching for relevant literature …………………………………………………………………………………………………………………… 13 Selection of studies …………………………………………………………………………………………………………………………………….. 13 Data management ………………………………………………………………………………………………………………………………… 13-14 Analysis ……………………………………………………………………………………………………………………………………………………. 14 RESULTS ……………………………………………………………………………………………………………………………………………………. 15 Patterns of HIV in Zimbabwe ………………………………………………………………………………………………………………………. 16 Masculinity and HIV ……………………………………………………………………………………………………………………………… 16-17 Masculinity and Risk ……………………………………………………………………………………………………………………………… 18-19 Masculinity and Power …………………………………………………………………………………………………………………………. 19-21 DISCUSSION ………………………………………………………………………………………………………………………………………………. 22 CONCLUSION AND RECOMMENDATIONS …………………………………………………………………………………………… 23 Prevention Strategies ………………………………………………………………………………………………………………………………….. 23 Identified Gaps……………………………………………………………………………………………………………………………………….. 23-24 Future Directions ……………………………………………………………………………………………………………………………………….. 24 Recommendations ……………………………………………………………………………………………………………………………….. 24-25 REFERENCES ……………………………………………………………………………………………………………………………………… 26-35 APPENDIXES Appendix 1…………………………………………………………………………………………………………………………………………………. 36 MASCULINITY AND HIV 1 Abstract Background Over the last two decades, gender has been found to be crucial for understanding Human Immunodeficiency Virus (HIV) transmission. The hypothesis for this study is that masculinity plays a key role in driving and shaping the HIV epidemic in Zimbabwe. With this knowledge, further studies are needed to unpack the interplay between gender, more specifically, masculinity, and the prevalence and patterns of the virus. While ongoing work on the interactions between femininity and women’s vulnerability to the HIV virus has been undertaken over recent decades – more attention will need to be directed at the role played by masculinities in HIV transmission. The decision to study the Southern African region, especially Zimbabwe was for several reasons. First, HIV/AIDS is a global pandemic and has presented as one of the worst population health and development challenges to face the global community – a challenge that has left many developing countries destabilized, with Zimbabwe being among the worst affected. Second, more attention has been historically put on the roles played by gender inequalities in expediting HIV transmission, especially, the vulnerability of women. While there is a growing literature on how masculinity interplays with the epidemic, insufficient attention has been paid to the impact of masculine ideologies in the Zimbabwean context may have had (and continue to have) on the spread of HIV. While I acknowledge that there are masculine ideologies which seem to be relatively consistent across nations, there are significant variations in how masculinity influences sexual practices and behaviors in different regions, countries, communities that also have major implications for the transmission of HIV. This review explores, how men often place themselves at a disadvantage when it comes to the HIV transmission when males subscribe to hegemonic masculinities and patriarchies. Men’s’ attitudes and behaviors when associated with hegemonic masculinity can therefore be deeply restrictive, if not risky. MASCULINITY AND HIV 2 Methods and Findings The literature covering masculinity and HIV in Zimbabwe and Southern Africa published between 2010 – 2016 was systematically reviewed using the PRISMA methodology. Historical literature was only followed up based on its relevance to studies identified in the above timeframe. All publications were identified online. The findings suggest that masculinity has had a significant effect on the epidemiology of HIV in Zimbabwe. The study covers a period when prevention strategies and research was more focused on the vulnerability of women regarding HIV. This was a global phenomenon, not only found in Zimbabwe, however, over the last decade there has been shift in services and understanding that while the vulnerability of women has been explored – there is recognition of the need to understand masculinities as the two aspects of gender work hand in hand. The literature suggests that notions and perceptions of masculinity have a huge impact in promoting the spread of HIV. Hegemonic masculinity defines ‘real men’ as strong, emotionally independent, tough, fearless and the economic provider, which makes it important for many men to act out and ‘prove’ their masculinity. The research suggests that men in Zimbabwe commonly uphold traditional notions of masculinity, however masculinities have changed. It is notable that prior to colonization hegemonic masculinity was different from contemporary versions. Because of differing cultures, practices, and historical events no single ‘pure’ version of “Zimbabwean Masculinity” can be said to have existed. Overall, it is evident that masculinities can promote risk-taking when they discourage sexual safety. However, masculinities are fluid and men are able to change their constructions of masculinity Conclusion Studies conducted of the past decade clearly suggests a relationship between masculinity and patterns of HIV in Zimbabwe. There is evidently an opportunity for work to be done in working with the Zimbabwean men, to challenge current notions of manhood and to promote constructive MASCULINITY AND HIV 3 masculinities that protect the populations from the adverse consequences of ‘high-risk’ masculinities. Key Words HIV, masculinity, masculinities, safe sex, condom use, sexuality, gender, risk taking, Southern African, Zimbabwe Definition of terms AIDS………………………… Acquired Immuno-Deficiency Syndrome ARV……………………….….Antiretroviral drugs WHO…………………………. World Health Organization UNAIDS ………………………United Nations Programme on HIV/AIDS HIV……………………………Human Immunodeficiency Syndrome UNICEF………………………United Nations Children’s Fund PSI……………………………Population Services International PMTCT………………………. Prevention of Mother to Child Transmission MASCULINITY AND HIV 4 Introduction Human Immunodeficiency Virus (HIV) and Global Impact Since HIV came to the fore in the early 80s in the United States, efforts to find an effective cure have been unsuccessful, however over time, treatments which prolong life with good quality have since been developed. Antiretroviral therapy (ART) is the good standard intervention for managing the HIV available to the public. HIV has 3 main stages of infection which mostly progresses when an individual does not access proper treatment. It can take over a decade for an individual who is infected to move from stage 1 to 3. The last stage, 3, is notably the most severe phrase of the infection known as AIDS (Acquired Immuno Deficiency Syndrome) and without treatment and proper care, most people will die within 3 years. There are over 35 million people living with HIV/AIDS in the world (UNAIDS, 2013. Source: UNAIDS 2015 Sub-Saharan Africa is the region most severely affected by the HIV epidemic (World Health Organization, 2007: Piot, 2015). The region has the highest HIV prevalence in the world 37.2 million infected by the virus residing within this region (Shanaube & Bock, 2015). Despite some MASCULINITY AND HIV 5 countries within the region gradually experiencing a HIV infection rate decline over the past years (UNICEF, 2015), two-digit infection rates remain the highest of all regions (UNAIDS, 2015) and 70 percent of new infections were recorded in this region (UNAIDS, 2011). Human Immunodeficiency Virus (HIV) in Zimbabwe Zimbabwe is a third world country located in the SADC region of Africa. It is landlocked between the Limpopo and Zambezi rivers, on the north of the Tropic of Capricorn, covering a total of 150,871 square miles (Esterhuysen, 2013). Zimbabwe is home to a total population of 13 million with a current population growth of around 1.1 percent. Source: World Map 2016 Source: World Map 2016 HIV/AIDS prevalence rates for Zimbabwe have been reported to be among the highest in the world and have remained high for over two decades 1980-2000s, gradually starting to reduce over the last decade. This is one of the two main African countries achieving a relatively significant incident decline rate from 29% in 1997 to 16% in 2007 (Halperin et. al, 2011) however the prevalence rates of 16.7 percent remain high in comparison to the rest of the world (UNAIDS, 2014). It is a global tragedy that definitely requires further planning and action to reduce these statistics. While there is wide awareness and knowledge concerning HIV MASCULINITY AND HIV 6 transmission in Zimbabwe and the greater parts of the Southern African region, the current prevalence and infection rate does not reflect this gained knowledge. Masculinity in Context Researchers have shown interest in masculinity and HIV over recent years. What is the definition of masculinity in Zimbabwe? What is the relationship between masculinities and the epidemiology of HIV in Zimbabwe. In understanding that HIV/AIDS is undeniably transmitted through social, more work needs to be done to carefully examine not only the socioeconomic, political or medical factors but to unpack the dynamics of gender expectations and taboos that impact on HIV statistics (Tadele, & Kloos, 2013). Masculinity is one such dynamic. While Zimbabwe is an independent country, it does not exist in solitude. The Southern African region where Zimbabwe is located has experienced HIV. Extensive work has been done and published in the “Southern African region” and some findings and can be generalised to Zimbabwe. Defining “masculinities “is essential because of varying notions from country to country, tribe to tribe even people within the same country and community. Acceptance and expectations can vary. On that same note, it is important to acknowledge that masculinity is fluid and can evolve depending on, social expectations, culture changes and other circumstances that can come into play. Historical writers in critical men’s studies also agree that masculinity is a social construct not an unchanging state of being and the community shapes masculinities within social, political and economic contexts. The ideologies construct meaning and roles and influence that men’s domineering need, risk taking behavior, strength are what makes a man a man (Jackson, Kaufman and Kimmel, 2010). Over the past decades, extensive work has been undertaken on women and HIV. Prevention strategies to engage women and empower them have been implemented in Zimbabwe over the past three decades. It is reported that women (in general) engage well with the HIV services and health promotion, however the question remains “why then are the infection and prevalence rates still very high when women seem to the responding well to prevention strategies? What is it about their partners that influence risks? Or rather, we MASCULINITY AND HIV 7 should now be asking, what is it about men that appears to disempower sexual partners from maintaining sexual safety. Purpose There are two purposes of this literature review. The primary objective is to have an understanding on masculinity and HIV/ AIDS interactions in Zimbabwe in a bid to provide suitable recommendations for policy makers and other identified stakeholders within the public sector. Improved understanding should assist to them to make informed decisions regarding policy implementation, prevention strategies and health promotion activities which will subsequently, if effectively implement, reduce the high HIV infection rate in Zimbabwe. There are a number of similarities between of masculinities in the SADC region, therefore this review might have value for other countries within this region to see if the recommendations might provide better guidance. Objectives The objectives of the Systematic Literature Review on Masculinity and HIV in Zimbabwe are as follows: Objectives 1. To understand the definitions and expectations of masculinity in the Southern African and Zimbabwean contexts. 2. To better understand the interaction between HIV epidemics and masculinity in Zimbabwe 3. To identify appropriate recommendations for the Zimbabwean Government, HIV practitioners, stakeholders, policy makers, nongovernmental organizations, public health practitioners, researchers, and service providers to assist in stemming the spread of the virus and the subsequent burden it causes. MASCULINITY AND HIV 8 Masculinity in Zimbabwe In the to pre-colonization era in Zimbabwe c500- 1889, the barter system was well organized at a time when men went to hunt and gather for their families and women tilled the land for food (Halperin, 1980). In this era, the survival of the family unit depended on good team work within individual households (Richartz,1905). Although culturally men were to be the dominating head of the family, and expected to be strong and risk taking, roles that seemed manly could only be filled by women if there was need (Mair, 1953). Men were expected to be the providers, indeed they were custodians of every aspect of life for their families and communities within the economic, social or political domains (Zeleza,1997). On the other hand, women were expected to carry out household chores, raise children, fetch water, firewood, cook and wash the dishes (Draper, 1975). Polygamy was normalized and most men who could provide for their families would bring more wives into the household (Mair & Harries, 1953). In contrast, in the 21st century, the traditional notions about men and masculinity in Zimbabwe are evolving, however, there are some traditional practices that are, to some degree upheld and stood the test of time. Moscovici (1961) developed a concept known as the “social representations theory”. The theory suggests that the world creates a system of values, ideas and practices for two major purposes. Firstly because of the need to develop stability and second to enable communication and interaction between individuals with the same understanding of what their social exchange expectations and histories are (Bhavnani, 1991). As we explore the social representation theory, we identify clearly that masculinity is socially created, fluid, and a shared gender identity. It is important to use the term ‘masculinities’, with the understanding that there is no one collective masculinity even within a country, tribe, community or even families, but rather accept that is has dynamic formations of gender expectations which can change in time, system and culture (Connell, 2000).With that understanding that a universally acceptable definition of masculinity is unattainable, according to Miffin (1995), masculinity is a set of qualities, characteristics and roles which are normally accepted or considered to be proper and fitting for a man. Traits which have come to symbolize MASCULINITY AND HIV 9 maleness in many settings include toughness, fierceness, endurance and sexuality (Gilmore, 1990). These underlying conceptions that inform masculinity have greatly influenced the current views about gender, equality, males and the social hierarchy. Hegemonic masculinity is a variant that has been used by many academics and authors in reference to ‘maleness’. Rather than being a form of masculinity, hegemonic masculinity can be best thought of as an idealized set of stereotypes which act as benchmarks Figure 2 below presents the cyclical pattern of how hegemonic masculinity is formed, duplicated, and perpetuated. In Zimbabwe, the patriarchal society has been suggested to be an enabler of the spread of HIV (Mugweni, Pearson & Omar, 2012). It is argued that gender inequality leads to power inequality as well as social and health inequality. Most parts of Southern African associate masculinity with the old-style ideas of what it means to be a man, including expectations that men to be macho, industrious, healthy, strong, brave, in control, sexually adventurous, risk taking and successful (Resser, 2011: Cubbins, Jordan, & Nsimba, 2014) Most publications on masculinities refer to men’s valuing of sexual interaction as a significant part as to what it means to be a man. These roles infer that masculinity needs continuous work for each man to maintain this status (Resser, 2011). MASCULINITY AND HIV 10 Unfortunately, these expectations can make it challenging and to an extent impossible for men to seek health services when they have been diagnosed with HIV (Jarrett, Bellammy, & Adeyemi 2007). Generally, men are not expected to appear weak and vulnerable, but rather always in control. These concepts frame “masculinity’ or “masculinities” is do vary within continents, regions, countries, communities and even cultural groups hence the necessity to explore further what the constructions of masculinities in the context of the Southern African region and then more specifically, Zimbabwe. Methodology When policymakers, government and stakeholders make significant decisions, they need to have confidence in the quality of evidence they will be using to make these decisions. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) research tool was adopted for this research. As indicated on figure 3. MASCULINITY AND HIV 11 PRISMA Flow Diagram Records identified through databases: COCHRANE, EMBASE, MEDLINE, PUBMED (n = 1541 ) Screening Included Eligibility Identification Additional records identified through other sources (n = 67 ) Records after duplicates removed (n 1214 ) Records screened (n = 971 ) Records excluded (n = ) Full-text articles assessed for eligibility (n 105 ) Full-text articles excluded, with reasons (n = ) Studies included in qualitative synthesis (n = ) Studies included 84 MASCULINITY AND HIV 12 STAGE 1 Inclusion Criteria The primary objective of this review was to systematically collect and review studies and research on HIV conducted within the Southern Africa region which supports the aim of this paper – understanding the relationship between masculinity and HIV in Southern Africa. The secondary objective of the review was to analyse the literature and subsequently identify relevant recommendations for stakeholders, policy makers, international nongovernmental organizations, public health practitioners and researchers. Searching for relevant literature In April of 2016, the electronic databases PubMed, GIDEON, MEDLINE, Cochrane, and Embase were accessed as the main databases used to search for relevant literature. Information also published on the websites of WHO, UNICEF, AVERT, OXFAM, UNAIDS was also considered. Griffith online Library was used during this stage. Research was limited to the literature published between the years 2011- 2016. The pre-determined search terms were HIV, Southern Africa, , risk taking, gender, sexuality, condom use, masculinity, masculinities and safe sex. Selection of research Based on the search strategy, a total of 1541 citations were identified (see Figure 1). After reviewing the title and/or abstract of all the citations and removing duplicate, 1201 citations were excluded as clearly irrelevant. The full text was retrieved for the remaining 105 studies and 47 studies were deemed to be relevant for the purposes of this paper. MASCULINITY AND HIV 13 STAGE 2 Searching for relevant literature In May of 2016, studies were identified through systematic searching using relevant search terms on electronic search databases (Pub Med, Medline, Cochrane, EMBASE,) for articles published between 2011 and 2016 (stage 1) and 2006 and 2016 (stage 2). Systematic Internet search engines (Google and Google scholar) for published and unpublished articles and reports were used. The following search terms were used to search the electronic database Medline and adapted for other electronic databases and Internet searching – HIV, Southern Africa, Risk taking, Gender, Sexuality, Condom use, Masculinity, Masculinities, Safe sex, Zimbabwe. Selection Criteria A search for evidence with a specific focus on information on Southern Africa and Zimbabwe was conducted. The writer then synthesized the evidence according to specific geographical regions. The synthesis and analysis were hindered by the vast work done mainly in South Africa but there was a lack of extensive data on masculinity in Zimbabwe. The writer did not have the opportunity to secure any other sources besides those accessible on the internet. All literature identified to be relevant to the aim of the review allowed the inclusion of any research and studies conducted within the Southern African region and Zimbabwe. There we no age limits in what is regarded as “man” when discussing Masculinities or their interactions with HIV patterns. The literature which qualified for inclusion had the ultimate goal of identifying masculine ideologies, traits and behaviours that have implications for the spread of HIV. Data Management The author methodically scanned the titles, summaries and abstracts to identify whether the publication was relevant for the purpose of this study. The identified documents were then examined, and generally discussed with supervisors for clarification and direction where there MASCULINITY AND HIV 14 were some doubts or concerns. All literature used for this research was from electronic documents, publishers, and reference sources. Analysis Based on the search strategy, a total of 1541 citations were identified (see Figure 1). After reviewing the title and/or abstract of all the citations and removing duplicate, 1201 citations were excluded as clearly irrelevant. The full text was retrieved for the remaining 105 studies and 47 studies were deemed to be relevant for the purposes of this paper. Limitations Limitations to this systematic review included limited research of the other 7 Southern African countries in comparison to the extensive work done in South Africa. Adding Zimbabwe as one of the key terms greatly increased the literature recovered. More citations than before were picked up by this search strategy and it was useful for narrowing down the volume. MASCULINITY AND HIV 15 Results Patterns of HIV in Zimbabwe Zimbabwe has experienced one of the world’s highest rates of HIV infection. In fact, the first case was recorded in the mid-80s and would see an exponential rise which resulted in the country averaging above 10 percent infection rates by 1990 (Kerina, Babill & Muller, 2013). Fig 3 below shows the HIV prevalence rates in Zimbabwe over a period of 17 years – from 1990 to 2015. This increase continued into the 2000s. At one point in the 1990s women recorded a high prevalence rate as high as 30 percent. HIV transmission through heterosexual partners was the main catalyst to this seemingly uncontrollable epidemic which accounted for an estimated 80 to 90 % of the transmissions (Kerina et al.,2013). At its peak, the prevalence stood at 26.48 percent in 1997, and rose to 29 percent by 1999 and it is around this time it started to slowly decline (Duri et al., 2013). MASCULINITY AND HIV 16 As indicated in the table above, the effects of HIV were evident in the fall of life expectancy in three SADC countries, Zimbabwe included. The country previously enjoyed a high life expectancy of 61 years in 1987 (World Bank, 2016), which sharply fell to an all-time low of 42 years by 2002 in part as a result of the HIV epidemic. Over the years, Zimbabwe has managed to achieve 50 percent incident rate reduction and we will explore what relationship these patterns might have had with Zimbabwean masculinities. Masculinity and HIV The areas identified as possibly contributing factors to high HIV infections rates which relate to masculinities in Southern Africa, include risky sexual behaviors (Lynch, Brouard, & Visser 2010), engaging in multiple sexual relationships, men’s power over women (Gupta, 2015), and men’s economic control power (Higgins et al 2010: Bhana and Pattman, 2011: Fox 2011). There are socially constructed factors associated with masculinity that potentially escalate the risk of HIV transmission in Zimbabwe. These factors include, cultural about what masculinity entails, patriarchal attitudes that spouses, girlfriends and children are their property and that men MASCULINITY AND HIV 17 expect or demand that their sexual desires are satisfied and fulfilled by women without question, objection or discussion. One area where men in Zimbabwe may be vulnerable to HIV relates to attitudes towards circumcision (Moyo, Mhloyi, Chevo, Rusinga 2015). Zimbabwean masculinity is phallocentric with the penis. It is regarded as a symbol of power and is token of sexual prowess. It is important essential that a Zimbabwean man is seen to be a lover with a high libido and stamina, one who is always able to “perform”. To some, the practice of circumcision is equated to physical castration or emasculation and as such, a threat to masculinity (Khumalo-Sakutukwa, van-Rooyen, Chingono, Humphries, Timbe, Morin, 2013). Circumcision is known to reduce heterosexual transmission of HIV infection, however there is a need for an overall change in behavior for a greater impact on transmission (Andersson, Owens, & Paltiel, 2011). Literature indicates that men who have been circumcised view this as . “risk ccompensation” and therefore minimize the need to use condoms (Koster, Bruinderink, & Janssens, 2015). A study in Zimbabwe indicated that men also had myths and misconceptions about circumcision that needed to be addressed through education (Kaufman, et al., 2016) (Hatzold, Mavhu, Jasi, Chatora, Cowan, Taruberekera, Njeuhmeli 2014). Higher HIV prevalence seems to cluster in areas where there are groups of men working away from home from long periods at a time. Studies have been conducted mines that suggest that men believe they have sexual needs that need to be regularly met (Corno, De Walque, 2012). Because these men are not able to easily return home, theywill eventually access sex with any women available. Discussions regarding HIV status and condom use are minimal and mostly arise in order to reach to a transactional cost of the act rather than out of fear of the virus (Skovdal et al.,2011). These findings are consistent with social constructions of masculinity where risk taking exposes men to a higher chance of HIV transmission. Many Zimbabwean men are therefore unwilling to risk their reputation, manhood and sexual performance despite the benefits of reducing their risk of acquiring a deadly virus. The fear of MASCULINITY AND HIV 18 erectile difficulties associated with circumcision threatens to disempower a man and, to him, he would no longer be able to classify himself as fully masculine. Masculinity and Risk While any military’s organizational culture tends to tolerate and in some instances support risktaking behavior byits staff, thismight influence staff to engage in high risk behaviors such as unprotected sex with multiple sexual partners (Mankayi & Naidoob, 2011). Soldiers will be required at some point to live away from their families because of the nature of their job. Other confounding issues such as working under pressure, work related stress and being away from their partners for an extended period of time have been identified as a contributing factor to high HIV prevalence rates across Southern Africa and Zimbabwe (Corno & De Walque, 2012). The underpinning perceptions regarding masculinity have aided in the fast spread of the virus. Undoubtedly, multiple, concurrent sexual relationships is an important determinant of HIV spread (Mah & Halperin, 2010). Concurrent sexual partnerships help to explain Africa’s high HIV prevalence (Lurie, & Rosenthal, 2010; Mah & Halperin, 2010). “Playing it safe” is not generally viewed as displaying masculinity and some men might find this very confronting. For a man wanting to retain the title of being a “real man”, there needs to be a sense of risk (Lurie & Rosenthal, 2010). Firstly, condom use has a number of underlying factors which a so-called “real man” will not opt for despite knowing the consequences of not using protection. Using a condom can affect the penis’ sensation and therefore a man’s ability to acquire or sustain an erection during sexual intercourse. Sexual underperformance or dysfunction is seen as a reputation threat especially if the sexual partner shares their experience with mutual friends or the community. In Zimbabwe, “kurova nyoro” (unprotected sex) has significance for the man as it implies power and higher social standing in regards to being “the man”, as well as the sexual gratification it is assumed to produce (Maleche, 2011). This desire to maintain a social standing unfortunately tends to disregard the risks associated with unprotected sex (Bhagwanjee, Govender, Reardon, MASCULINITY AND HIV 19 Johnstone, George, & Gordon, 2013). There is an increased chance of sexually transmitted infections which further promotes, HIV transmission. Furthermore, men (married, single, in long term stable relationships) commonly engage in multiple concurrent sexual relationships (Mavhu, 2011; Mugweni et al., 2015). A study conducted in 2010 -2011 reported that 14% of married men were in multiple concurrent relationships (Mugweni, Pearson, Mayeh, 2015). Literature suggests that masculine men are supposed to have an unquenchable appetite for sex (Mugweni et al., 2015). Men can engage the services of a sex worker or “small house” which simply put, is a long-term girlfriend on-the-side who is almost an unofficial wife. Thus this practice is treated as a norm (Mavhu, Langhaug, Pascoe, Dirawo, Hart, 2011 & Cowan, 2011); Mugweni et al.,2015). The HIV risk is sharply increased considering female sex workers are 13.5 times more likely to be HIV positive (Ramjee & Daniels 2013).A recent study in Zimbabwe reflected that men who identified as having simultaneous sexual relationships based their behaviour on the expectations of the notions of masculinity (Mugweni, Omar & Pearson, 2015) ; (Mavhu, Langhaug, Pascoe, Dirawo, Hart & Cowan, 2011). Historically, if a man acquired a sexually transmitted infection, it was considered to be a trait of masculinity although it was in fact disgraceful for a woman to suffer a similar disease (Halperin et al., 2011). Evidence of multiple partners suggests boldness and manly behavior as opposed to safe play. In a bid to prove themselves to other men and as well women, men would have children as evidence of their behavior, despite the fact that they would likely deny being the father. Masculinity and Power One trait associated with masculine behavior is the ability for a man to have control and power over a sexual partner (UN, 2012). This has been widely discussed in the of literature in relation to gender inequality. The results in marital relationships has inevitably led to high HIV infection rates within marriages. A man who exercises this power makes sexual demands that woman cannot negotiate including having unprotected sex. MASCULINITY AND HIV 20 Power includes economic power (financial), physical power and socially constructed power afforded to men within the Zimbabwean context (Chitando et al., 2012). In all casesmen’s power can fuel the HIV epidemic. In regards to economic power, and Zimbabwe’s economic crisis, men found it easy to use their financial leverage to get their sexual needs met by women on their own terms (UN, 2012). This power imbalance in heterosexual relationships promotes a disadvantaging silence among women as they accept the situation as a cultural requirement “being a man” and therefore being acceptable rather than being seen as sexual coercion or manipulation (Chitando et al., 2012). Being a man in Zimbabwe comes with the understanding that there is an expectation of being a provider (economically) and a having a higher social status in comparison to women. According to Gupta (2015) one of the most extreme displays of power manifest as perpetrating violence against women, including sexual violence. Being masculine is associated with “aggressiveness”, which constrains the ability of sexual partners to discuss sex, negotiate the use of a condom, visiting the New Start Centre for testing or even abstinence for the unmarried. Social explanations of sexuality are intimately connected withperceptions of gender and power (Tamale, 2011). Sexuality therefore is not defined by mere biological maleness, but by the expression of traits embedded in definitions of masculinity. In the case ofmen who have sex with men, and present with feminine traits such as “softness andemotional vulnerability are more likely to be overpowered by masculine men, (Ratele, 2011). Similar to women, men who have sex with men will not always be in a position to negotiate sexual decisions. Ratele (2011) further suggests that heterosexual men feel exposed by homosexuality as men having sex with men undermines the masculine gender structure that reinforcesmale hegemony over women and fear that these hegemonic perceptions will be deconstructed. Hegemonic masculinity is premised on the idea of male superiority, this creates an expectation for men to demonstrate this by exercising their control over women (Gupta, 2015; Chitando et al., 2012). This situation is further enhanced by the cultural practice in Zimbabwe of men paying bride price for a woman known traditionally as “lobola” (Naimasiah, 2014). This is done as a customary marriage and this money is paid to the girl’s family according to their request, however many parents use this for wealth accumulation and “lobola” is now the equivalent of a MASCULINITY AND HIV 21 transaction of purchase which also satisfies the masculine need for dominance through ownership (Chireshe & Chireshe, 2010). A study conducted in one of the largest towns Bulawayo, indicated that men felt that after paying the bride-price, the woman would be an asset, implying that the men had the authority and power to do anything with her asshe is his property. The transactional nature of marriage leaves married women in a compromised position and men with unjust power. Furthermore, cultural practices which promote hegemonic masculinity are still practiced. A good example would be the practice that encourages young pubescent girls to extend their labia majora by gradually pulling at them with their fingers to ensure that they provide sexual satisfaction to their future husbands. Men as suitors and providers supply girls and women with gifts, money and other needs that they may have (Bhana, & Pattman, 2011). Being a provider is desired by many men (Skovdal et al, 2011). In some instances, reported in Zimbabwe, women can opt to have an extra marital affair mainly for financial or economic advantages. It is not unusual for a man to marry more wives as he gains wealth, in fact, this is considered an acceptable practice (Mavhu, Langhaug, Pascoe, Dirawo, Hart, 2011). The community notices that the man has many wives and he can economically provide for them and his status increases accordingly. Polygamy remains common in the country, especially in rural and remote areas. At least two Southern African Heads of States are in polygamous relationships. King Muswati, who conducts a cultural and annual feast titled “Mhlanga”, or the reed dance “and all young virgins over 18 years of age can participate and dance almost naked (only wearing a traditional skirt), and he, as the King would, as custom pick a new wife from among those young girls (Ramdeen, & Ngubane, 2015). Clearly the need to satisfy notions of masculinity can promote the transmission of HIV. Similarly, Jacob Zuma, of South Africa has five wives. Polygamy, can easily act as a catalyst to spreading the virus. MASCULINITY AND HIV 22 Discussion Pubescent boys, young men and older men in both rural and urban areas in Southern Africa (and Zimbabwe) have consistently reported struggles with intense sexual desires, strong peer pressures to have sex, and social norms discouraging condom use (Keene, 2011). How these constructions influence behavior is pivotal to understanding the connectedness of masculinity and HIV. The ABC prevention strategy promotes “Abstinence’, ‘Be Faithful’ or ‘Use Condoms (Bertrand, 2015)– all three aspects which go against masculinities ideologies such as risk taking, emotional restraint and high sexual desire (Morrell, et al., 2012). Past sexual health promotion focused more on women and their vulnerability and subsequently developed more programs to empower women. While this is a key strategy, HIV reduction would be impossible without working with both men and women. Over the years, other factors seem to have influenced a change in the behaviour of men towards HIV transmission. One of these factors can be linked with hegemonic masculinity, in a positive way. Men have seen family members, siblings, uncles suffer from AIDS, watched other men being wasted and loosing dignity and these potentially rob a man of any respect from women, other men and the society at large, however the perceptions remain that masculine men should have power and control at all times. (UNAIDS, 2012) A key factor that contributed to the decline of HIV incidence in Zimbabwe was a reduction in multiple sexual partners, over 30% drop in extra marital affairs (UNAIDS, 2011). Men started to spend less money on women due to the financial crisis in Zimbabwe, which left them unable to sustain multiple relationship or to engaging the services of sexworkers. Some studies also indicated that once some men were advised of their HIV positive status, their high risk sexual behaviors subsided in fear of superinfection with another strain of HIV. In both circumstances, it is apparent that men are able to configure their masculinity to suit their limited financial/economic circumstances as well as their fear of reinfection. Masculinity is not “hard wired”. MASCULINITY AND HIV 23 Prevention Strategies There have been countless HIV/AIDS interventions, policies and strategies over the last two decades. Most HIV prevention strategies in Africa were developed and implemented without consideration of social, traditional, economic and governmental contexts of HIV/AIDS and masculinities in the region. This has resulted in the failure of many of these programs to perform to expectations. Over the years, interventions and strategies which identified women to be at the forefront of HIV vulnerability have been implemented by health services, researchers and have been included in the policies introduced by various governments. Within the last 10 years, efforts to end the spread of the epidemic by states and global development partners have yielded more positive results. Countries including Botswana, Zambia and Zimbabwe have managed to reduce the infection rate by over 50 percent (UNICEF, 2015); although the statistics are still high with one in every 10 infected in Mozambique; in South Africa the rate is approximately one in eight people, and Zimbabwe, being one of the worst affected countries, one in six people is living with HIV (UNICEF, 2015). Identified Gaps Southern Africa, more particularly, Zimbabwe, has completed much valuable work to implement the most suitable prevention strategies for the sub-continent. While it was relatively easy to identify that the transmission of this virus is principally through heterosexual sexual relationships, there are additional underpinning factors that have caused the infection rate to remain higher. The most promising ways would then be to introduce prevention programs that will tackle the issue at its core, the notions of hegemonic masculinity. More work can be done to provide: • More male lead interventions • National Behavior Change Programmes MASCULINITY AND HIV 24 • Consideration of different cultural groups within Zimbabwe • Gender focused Voluntary, Counselling, and Testing Services • Focusing on diverse masculinities Future Directions Zimbabwe is one of 189 nations that have devoted themselves to an all-inclusive program of embracing the United Nations General Assembly Special Session (UNGASS) declaration of commitment on HIV and AIDS of June 2001 in a bid to halt the spread of HIV. It is known that many actors, organizations, government policy makers, academics and human rights activists agree that gender roles have been linked to the diverse aspects of unequal of power and basic human rights Zimbabwe and the SADC regions now need relevant policies that would be applicable and efficient in reducing the spread of HIV not least using agenda lens. Recommendations 1. HIV prevention strategies for Zimbabwe should be developed with great regard and consideration of the current cultural practices and socially constructed notions of masculinities in the country. The two main groups within Zimbabwe, the Shonas and the Ndebeles should be engaged and identify and specific variations which might be relevant and make a difference. 2. Promotion of sexual and family responsibility among young boys and men should be a focus in Zimbabwe. This will allow men to examine the destructive effects of the socially constructed notions of masculinity and male power. School and work based programmes should be introduced where a reversal of past miseducation on what it means to be a man be included. Zimbabwe has an active education system that can easily allow for these programs to be easily implemented. 3. Uganda successfully implemented the ABC prevention program with very successful results despite criticisms from other nations. It is recommended to compare Zimbabwe’s MASCULINITY AND HIV 25 implementation plan for the same programme and identify the gaps on Zimbabwe’s implementation strategy based on review of how Uganda implemented their programme. HIV is a public health concern which I believe countries need to work together in order to be able to effectively combat it. 4. Informal meeting groups for men and young boys (both HIV positive and negative) to be organised in strategic centres where training on masculinities, relationships and risk reduction are a priority. 5. Easier access to ARVs. Most men still need education and information on where and how to access ARV on time as it has been noted that they present at their later stages of infection. Conclusion We know that hegemonic masculinity notions include, among others, risk taking behaviours, high sexual expectations, stoicism, strong emotional management and higher economic power. Further bout which traits affect epidemiology the most should to be a priority. Studies conducted of the past decade clearly suggests a relationship between masculinity and patterns of HIV in Zimbabwe. There is evidently an opportunity for work to be done in working with the Zimbabwean men, to challenge current notions of manhood and to promote constructive masculinities that protect the populations from the adverse consequences of ‘high-risk’ masculinities. Masculinity is not “hard wired”. MASCULINITY AND HIV 26 References Andersson, K. M., Owens, D. K., & Paltiel, A. D. (2011). Scaling up circumcision programs in Southern Africa: the potential impact of gender disparities and changes in condom use behaviors on heterosexual HIV transmission. AIDS and Behavior, 15(5), 938-948. Bandali, S. (2013). HIV risk assessment and risk reduction strategies in the context of prevailing gender norms in rural areas of Cabo Delgado, Mozambique. Journal of the International Association of Providers of AIDS Care (JIAPAC), 12(1), 50-54. Bertrand, R. L. (2015). Aids prevention in sub-Saharan Africa: as easy as ABC?. African Journal of Infectious Diseases, 10(1), 1-9. Bhagwanjee, A., Govender, K., Reardon, C., Johnstone, L., George, G., & Gordon, S. (2013). Gendered constructions of the impact of HIV and AIDS in the context of the HIV-positive seroconcordant heterosexual relationship. Journal of the International AIDS Society, 16(1). Bhana, D., & Anderson, B. (2013). Gender, relationship dynamics and South African girls’ vulnerability to sexual risk. African Journal of AIDS Research,12(1), 25-31. Bhana, D., & Pattman, R. (2011). Girls want money, boys want virgins: The materiality of love amongst South African township youth in the context of HIV and AIDS. Culture, Health & Sexuality, 13(8), 961-972. MASCULINITY AND HIV 27 Brown, J., Sorrell, J., & Raffaelli, M. (2005). An exploratory study of constructions of masculinity, sexuality and HIV/AIDS in Namibia, Southern Africa. Culture, health & sexuality, 7(6), 585-598. Bujra, J. (2000). Targeting men for a change: AIDS discourse and activism in Africa. Agenda, 16(44), 6-23. Campbell, C., Nhamo, M., Scott, K., Madanhire, C., Nyamukapa, C., Skovdal, M., & Gregson, S. (2013). The role of community conversations in facilitating local HIV competence: case study from rural Zimbabwe. BMC Public Health,13, 354. Campbell, C., Skovdal, M., Madanhire, C., Mugurungi, O., Gregson, S., & Nyamukapa, C. (2011). “We, the AIDS people …”: How Antiretroviral Therapy Enables Zimbabweans Living With Aids to Cope With Stigma. American Journal of Public Health, 101(6), 1004–1010. Chireshe, E., & Chireshe, R. (2010). Lobola: The perceptions of great Zimbabwe university students. Journal of Pan African Studies, 3(9), 211-221 Conroy, A. A., McGrath, N., van Rooyen, H., Hosegood, V., Johnson, M. O., Fritz, K., … & Darbes, L. A. (2016). Power and the association with relationship quality in South African couples: Implications for HIV/AIDS interventions. Social Science & Medicine, 153, 1-11. Corno, L., & De Walque, D. (2012). Mines, migration and HIV/AIDS in Southern Africa. Journal of African Economies, ejs005. Cooper, A., García, M., Petrovas, C., Yamamoto, T., Koup, R. A., & Nabel, G. J. (2013). HIV-1 causes CD4 cell death through DNA-dependent protein kinase during viral integration. Nature, 498(7454), 376-379. MASCULINITY AND HIV 28 Cubbins, L. A., Jordan, L. P., & Nsimba, S. E. (2014). Tanzanian men’s gender attitudes, HIV knowledge, and risk behaviours. Etude de la population africaine= African population studies, 28(2), 1171. Dageid, W., Govender, K., & Gordon, S. F. (2012). Masculinity and HIV disclosure among heterosexual South African men: implications for HIV/AIDS intervention. Culture, health & sexuality, 14(8), 925-940. Draper, P. (1975). ! Kung women: contrasts in sexual egalitarianism in foraging and sedentary contexts. Esterhuysen, P. (Ed.). (2013). Africa A to Z: Continental and Country Profiles. Africa Institute of South Africa. Fox, A. M. (2010). The social determinants of HIV serostatus in Southern African Africa: an inverse relationship between poverty and HIV?. Public Health Reports, 16-24. Gilmore, D. D. (1990). Manhood in the making: Cultural concepts of masculinity. Yale University Press. Gorski, E. (2010). Stoic, stubborn, or sensitive: How masculinity affects men’s help-seeking and help-referring behaviors’. UW-L Journal of Undergraduate Research, 13, 1-6. Gregson, S., Mushati, P., Grusin, H., Nhamo, M., Schumacher, C., Skovdal, M., … & Campbell, C. (2011). Social capital and women’s reduced vulnerability to HIV infection in rural Zimbabwe. Population and development review, 37(2), 333-359. Gregson, S., Nyamukapa, C. A., Sherr, L., Mugurungi, O., & Campbell, C. (2013). Grassroots community organizations’ contribution to the scale-up of HIV testing and counselling services in Zimbabwe. AIDS (London, England),27(10), 1657–1666. MASCULINITY AND HIV 29 Gregson, S., Nyamukapa, C., Schumacher, C., Magutshwa-Zitha, S., Skovdal, M., Yekeye, R., … Campbell, C. (2013). Evidence for a contribution of the community response to HIV decline in eastern Zimbabwe? AIDS Care, 25(Suppl 1), S88–S96. Gregson, S., & Murungi, O. (2006). HIV decline accelerated by reductions in unprotected casual sex in Zimbabwe. Evidence from a comprehensive epidemiological review. The. Halperin, R. (1980). Ecology and Mode of Production: Seasonal Variation and the Division of Labor by Sex among Hunter-Gatherers. Journal of Anthropological Research, 36(3), 379-399. Halperin DT, Mugurungi O, Hallett TB, Muchini B, Campbell B, Magure T, et al. (2011) A Surprising Prevention Success: Why Did the HIV Epidemic Decline in Zimbabwe? PLoS Med 8(2): Hatzold, K., Mavhu, W., Jasi, P., Chatora, K., Cowan, F. M., Taruberekera, N., … Njeuhmeli, E. (2014). Barriers and Motivators to Voluntary Medical Male Circumcision Uptake among Different Age Groups of Men in Zimbabwe: Results from a Mixed Methods Study. PLoS ONE, 9(5), e85051. Harrison, A., O’sullivan, L. F., Hoffman, S., Dolezal, C., & Morrell, R. (2006). Gender role and relationship norms among young adults in South Africa: measuring the context of masculinity and HIV risk. Journal of Urban Health,83(4), 709-722. Higgins, J. A., Hoffman, S., & Dworkin, S. L. (2010). Rethinking gender, heterosexual men, and women’s vulnerability to HIV/AIDS. American Journal of Public Health, 100(3), 435-445. Hunter, M. (2005). Cultural politics and masculinities: Multiple-partners in historical perspective in KwaZulu-Natal. Culture, health & sexuality, 7(4), 389-403. MASCULINITY AND HIV 30 Jewkes, R., & Morrell, R. (2010). Gender and sexuality: emerging perspectives from the heterosexual epidemic in South Africa and implications for HIV risk and prevention. Journal of the International AIDS society, 13(1), 6. Joseph, B., Nair, P. M., & Nanda, A. (2015). Effects of naturopathy and yoga intervention on CD4 count of the individuals receiving antiretroviral therapy-report from a human immunodeficiency virus sanatorium, Pune. International journal of yoga, 8(2), 122. Joint United Nations Programme on HIV/AIDS., & World Health Organization. (2007). AIDS epidemic update. World Health Organization. Kaufman, M. R., Smelyanskaya, M., Lynn M Van Lith, Mallalieu, E. C., Waxman, A., Hatzhold, K.. . Njeuhmeli, E. (2016). Adolescent sexual and reproductive health services and implications for the provision of voluntary medical male circumcision: Results of a systematic literature review: E0149892. PLoS One, 11(3) Kerina, D., Babill, S. P., & Muller, F. (2013). HIV/AIDS: The Zimbabwean situation and trends. American Journal of Clinical Medicine Research, 1(1), 15-22. Khumalo-Sakutukwa, G., Lane, T., van-Rooyen, H., Chingono, A., Humphries, H., Timbe, A., … Morin, S. F. (2013). Understanding and Addressing Socio-Cultural Barriers to Medical Male Circumcision in Traditionally Non-Circumcising Rural Communities in Sub-Saharan Africa. Culture, Health & Sexuality, 15(9), Koster, W., Bruinderink, M. G., & Janssens, W. (2015). Empowering women or pleasing men? analyzing male views on female condom use in zimbabwe, nigeria and Cameroon. International Perspectives on Sexual and Reproductive Health, 41(3), 126-135. MASCULINITY AND HIV 31 Lurie, M. N., & Rosenthal, S. (2010). Concurrent partnerships as a driver of the HIV epidemic in sub-Saharan Africa? The evidence is limited. AIDS and Behavior, 14(1), 17-24. Lindegger, G., & Durrheim, K. (2001). Men, HIV/AIDS and the crisis of masculinity. Sociopolitical and psychological perspectives on South Africa, 229-250. Loud, W. O. (2012). how women living with HIV will help the world end AIDS. Geneva: UNAIDS. Maartens, G., Celum, C., & Lewin, S. R. (2014). HIV infection: epidemiology, pathogenesis, treatment, and prevention. The Lancet, 384(9939), 258-271. Mair, L. P., & Harries, L. (1953). Survey of African marriage and family life. A. Phillips (Ed.). International African Institute. Mah, T. L., & Halperin, D. T. (2010). Concurrent sexual partnerships and the HIV epidemics in Africa: evidence to move forward. AIDS and Behavior,14(1), 11-16. Maleche A, Day E: Working Paper for the Third Meeting of the Technical Advisory Group of the Global Commission on HIV and the Law, 7–9 July 2011. Traditional cultural practices and HIV: reconciling culture and human rights. 2011 Mavhu, W., Langhaug, L., Pascoe, S., Dirawo, J., Hart, G., & Cowan, F. (2011). A novel tool to assess community norms and attitudes to multiple and concurrent sexual partnering in rural zimbabwe: Participatory attitudinal ranking. AIDS Care,23(1), 52-59. Mapenzauswa S. Zimbabwe Holds First National Meeting on AIDS Crisis”, June 15, 2004. 2004. Reuters NewsMedia. MASCULINITY AND HIV 32 Masvawure, T. B., Terry, P. E., Adlis, S., & Mhloyi, M. (2009). When ‘‘No’’ means ‘‘Yes’’: The gender implications of HIV programming in a zimbabwean university. Journal of the International Association of Physicians in AIDS Care, 8(5), 291-298. Mavhu, W., Hatzold, K., Laver, S. M., Sherman, J., Tengende, B. R., Mangenah, C., … Cowan, F. M. (2012). Acceptability of Early Infant Male Circumcision as an HIV Prevention Intervention in Zimbabwe: A Qualitative Perspective. Mavhu, W., Dauya, E., Bandason, T., Munyati, S., Cowan, F. M., Hart, G., … Chikovore, J. (2010). Chronic cough and its association with TB-HIV co-infection: factors affecting helpseeking behaviour in Harare, Zimbabwe.Tropical Medicine & International Health: TM & IH, 15(5), 574–579. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): Moyo, S., Mhloyi, M., Chevo, T., & Rusinga, O. (2015). Men’s attitudes: A hindrance to the demand for voluntary medical male circumcision–A qualitative study in rural Mhondoro-Ngezi, Zimbabwe. Global public health,10(5-6), 708-720. Morrell, R. (1998). Of boys and men: masculinity and gender in Southern African studies. Journal of Southern African Studies, 24(4), 605-630. Morrell, R., Jewkes, R., & Lindegger, G. (2012). Hegemonic masculinity/masculinities in South Africa: Culture, power, and gender politics. Men and Masculinities, Morrell, R. (Ed.). (2001). Changing men in southern Africa. Zed books. Hunter M. Masculinities and multiple-sexual-partners in KwaZulu-Natal: the making and unmaking of Isoka. Transformation 2004; 54: 123–53 MASCULINITY AND HIV 33 Muchini, B., Benedikt, C., Gregson, S., Gomo, E., Mate, R., Mugurungi, O., … Halperin, D. (2011). Local Perceptions of the Forms, Timing and Causes of Behavior Change in Response to the AIDS Epidemic in Zimbabwe. AIDS and Behavior, 15(2), 487–498. Mugweni, E., Pearson, S., & Omar, M. (2015). Concurrent sexual partnerships among married Zimbabweans – implications for HIV prevention. International Journal of Women’s Health, 7, 819–832. Musheke, M., Ntalasha, H., Gari, S., Mckenzie, O., Bond, V., Martin-Hilber, A., & Merten, S. (2013). A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in Sub-Saharan Africa. BMC Public Health, 13, 220. Mugweni, E., Pearson, S., & Omar, M. (2012). Traditional gender roles, forced sex and HIV in Zimbabwean marriages. Culture, health & sexuality,14(5), 577-590. Mugweni, E., Omar, M., & Pearson, S. (2015). Understanding barriers to safer sex practice in zimbabwean marriages: Implications for future HIV prevention interventions. Health Education Research, 30(3), 388-399. doi:10.1093/her/cyu073 Mukenge, C. (2012). Black women sexualities and the female condom campaign in the context of HIV and AIDS in zimbabwe. International Proceedings of Economics Development and Research, 56, 99. Munhenga, C. Eighty percent of prostitutes who have gone for HIV testing in the past five years in Zimbabwe have been found positive. Muparamoto, N. (2012). ‘Trophy-hunting scripts’ among male university students in Zimbabwe. African Journal of AIDS Research, 11(4), 319-326. Myers, J. E., Xia, Q., Torian, L. V., Irvine, M., Harriman, G., Sepkowitz, K. A., & Shepard, C. W. (2016). Implementation and Operational Research: CD4 Count Monitoring Frequency and MASCULINITY AND HIV 34 Risk of CD4 Count Dropping Below 200 Cells Per Cubic Millimeter Among Stable HIVInfected Patients in New York City, 2007–2013. Journal of acquired immune deficiency syndromes (1999),71(3), e73. Piot, P. (2015). Hyperendemic HIV in southern africa. () Columbia University Press Poulin, M. (2007). Sex, money, and premarital partnerships in southern Malawi. Social science & medicine, 65(11), 2383-2393. Ramjee, G., & Daniels, B. (2013). Women and HIV in Sub-Saharan Africa.AIDS Research and Therapy, 10, 30. Ramdeen, M., & Ngubane, S. (2015). Swaziland. In Africa Yearbook Volume 11 (pp. 491-495). Brill. Richartz, F. J. Habits & customs of the Mashonas [Zambesi Mission Record, 1: 551-53: 1905] ». Descr. musical bow, drums, rattles & dances. Schmidt, E. (1988). Farmers, Hunters, and Gold-Washers: A Reevaluation of Women’s Roles in Precolonial and Colonial Zimbabwe. African Economic History, (17), 45-80. doi:1. Sambisa, W., Curtis, S., & Mishra, V. (2010). AIDS stigma as an obstacle to uptake of HIV testing: evidence from a Zimbabwean national population-based survey. AIDS care, 22(2), 170- 186. Scott, K., Campbell, C., Madanhire, C., Skovdal, M., Nyamukapa, C., & Gregson, S. (2014). In what ways do communities support optimal antiretroviral treatment in Zimbabwe? Health Promotion International, 29(4), 645–654. Shamu, S., Abrahams, N., Temmerman, M., Shefer, T., & Zarowsky, C. (2012).“That Pregnancy Can Bring Noise into the Family”: Exploring Intimate Partner Sexual Violence during Pregnancy in the Context of HIV in Zimbabwe. PLoS ONE, 7(8), e43148. MASCULINITY AND HIV 35 Shanaube, K., & Bock, P. (2015). Innovative Strategies for Scale up of Effective Combination HIV Prevention Interventions in Sub-Saharan Africa.Current HIV/AIDS Reports, 12(2), 231-237. Sidler D, Smith J, Rode H. Neonatal circumcision does not reduce HIV infection rates. S Afr Med J 2008; 98: 764-766 Skovdal, M., Magutshwa-Zitha, S., Campbell, C., Nyamukapa, C., & Gregson, S. (2013). Community groups as “critical enablers” of the HIV response in Zimbabwe. BMC Health Services Research, 13, 195. Skovdal, M., Campbell, C., Nyamukapa, C., & Gregson, S. (2011). When masculinity interferes with women’s treatment of HIV infection: a qualitative study about adherence to antiretroviral therapy in Zimbabwe. Journal of the International AIDS Society, 14, 29. Skovdal, M., Campbell, C., Madanhire, C., Mupambireyi, Z., Nyamukapa, C., & Gregson, S. (2011). Masculinity as a barrier to men’s use of HIV services in Zimbabwe. Globalization and Health, 7, 13. Sovran, S. (2013). Understanding culture and HIV/AIDS in sub-Saharan Africa.Sahara J, 10(1), 32–41. Swidler, A., & Watkins, S. C.. (2007). Ties of Dependence: AIDS and Transactional Sex in Rural Malawi. Studies in Family Planning, 38(3), 147–162. Tadele, G., & Kloos, H. (Eds.). (2013). Vulnerabilities, Impacts, and Responses to HIV/AIDS in Sub-Saharan Africa. Palgrave Macmillan. Thobejane, T. D., & Flora, T. (2014). An Exploration of Polygamous Marriages: A Worldview. Mediterranean Journal of Social Sciences, 5(27 P2), 1058. MASCULINITY AND HIV 36 Zeleza, P. T. (1997). Gender biases in African historiography. Appendix 1 Table HIV prevalence by sexual behavior MASCULINITY AND HIV 37 Sexual behavior characteristic % of HIV positive Women Number Women % of HIV positive Men Number Men Total Age at first sexual intercourse