What Are Heterosexual Men's HIV Prevention Needs?
Are heterosexual men at risk?
Yes. In the US, new AIDS cases are increasing among people who were infected through injecting drug use (IDU) and heterosexual sexual contact.1 The rise in IDU infections in heterosexual men has led to the rise in HIV infections in women, as more women become infected from men who are IDUs. For this reason, sexual behavior change among heterosexual men will be key to controlling the HIV epidemic for heterosexual men, women and children.
Over one-fourth (28%) of all AIDS cases among men in the US occurred through injection drug use and heterosexual sexual contact. Over three-fourths of those cases were among men of color, with African-American men comprising more than half (55%).2 AIDS and HIV cases are classified by drug use and sexual act, and not by self-identification. Heterosexually-identified men that engage in sex with other men are classified as “men who have sex with men.” However, they may not relate to programs targeting gay men.
Prevention programs in the US have addressed the drug-using risks of heterosexual men. However, few have addressed their sexual behavior. Women have been the primary focus of sexual behavior change among heterosexuals. If heterosexually-identified men are reached, often it is by default because the intervention was targeting another audience.
What puts men at risk?
Injection drug use poses the highest risk to heterosexual men.2 Use of other non-injected substances such as methamphetamines, crack cocaine and alcohol can increase sexual risk taking, which increases risk of HIV infection. A study of out-of-treatment IDUs in California found that heterosexual men who used methamphetamines reported more sex partners, more sexual activity—including anal intercourse with men and women—and less condom use than men who did not use methamphetamines. In addition, half of their regular female partners did not inject drugs.3
Men can get infected from having unprotected intercourse with an HIV+ woman, although the risk is much lower than the risk from sharing infected injection equipment or having sex with an HIV+ man. The risk increases when men or their female partners have STD infections.4 The greatest sexual risk behavior for heterosexual men is unprotected anal sex with an HIV+ man. Because of homophobia and fear of rejection, men may be unlikely to report having sex with men, identifying sex with women as their only risk factor.5
Men in certain settings are at greater risk. In the US, 90% of prisoners are men. Among the incarcerated, rates of HIV are 8-10 times higher than in the general population.6 Injection drug use, other illicit drug use, tattooing and unprotected anal sex with other men are all risk behaviors for HIV in prison or jail. Clean needles are not available in jail and prisons in the US and condoms are only available in a few.
What makes prevention difficult?
Men in this society are not trained or coached to develop a health plan for themselves. Between childhood vaccinations and post-middle age checks for prostate cancer, many heterosexual men typically do not visit a doctor's office.7 Heterosexual men and African Americans in particular, are least likely to be tested for HIV, enter into treatment, and keep medical appointments.8,9
Many heterosexual men do not have enough knowledge about HIV and other STDs, and do not believe it concerns them. HIV is still seen as a "gay white man's” problem because of the lack of materials targeted to straight men and lack of heterosexual peer educators. Men may be reluctant to use HIV/AIDS services that are run by or targeted to gay men.
Men wear the (male) condom and ultimately have the power to use them or not. Men may be concerned about pregnancy, STD and HIV prevention, but may have difficulty bringing up the subject of condoms with their partners. Some men wait for the female partner to begin that discussion—if she doesn't, they often do not mention condoms themselves.10
Young men of color often see themselves as an "endangered species."11 For many inner-city youth, the dangers and concerns of daily survival far outweigh any future concerns such as HIV. The realities of poverty, violence and addiction enforce Black men's belief that they will not live past the age of 25. For many inner-city youth, the likelihood of being shot or sent to prison is their greatest concern.11
How can heterosexual men be reached?
Peer educators can help address HIV prevention to heterosexual men, yet very few heterosexual men are involved in HIV prevention. Fear and misunderstanding about gay culture further inhibit involvement. Sensitivity training is necessary for all men to understand and respect sexual cultures and boundaries.
Recruiting heterosexual men can be a difficult task. For instance, approaching African American men individually may not be as effective as recruiting them through their employer, mentor, religious leader or social group.12 Heterosexual men also may need encouragement from girlfriends or wives to participate in HIV prevention programs.12
Campaigns that target heterosexual men should focus on general health issues, not sexual issues. Campaigns should encourage men to talk about and take responsibility for their health and well-being, instead of highlighting the negative side of sex (HIV kills, sex with a minor can land you in jail). Education should begin before adolescence to help young men protect themselves as they are confronted with the world of sexuality and substance use.
What's being done?
A video-based, skills-building HIV prevention program for African American heterosexual men in Atlanta, GA, helped increase rates of condom use and lower unprotected vaginal intercourse. The program showed videotaped HIV information, questions and answers about HIV and condom use demonstrations. It also incorporated live facilitators. Because men were unlikely to participate in sexual role-playing with other men, the program used clips from popular movies and asked the men to suggest dialogue for safer sex.13
Le Penseur Youth Services reaches out to young people and families in Southeast Chicago, IL. One program targets young male gang members by using gang leaders as peer educators. Le Penseur trained gang leaders and members to deliver safer sex messages. A key component of the program is giving young men clear roles and opportunities for advancement and leadership. Using gang members drove home the point that HIV affects heterosexual men, and increased awareness of HIV in the community.14
In Baltimore, MD, the health department opened a free Men's Health Center to address the health care needs of uninsured men ages 19-64. The clinic provides primary and dental care, substance abuse counseling, job placement and prevention education. The doctor, nurse and physician's assistant are all men. When it opened, it was the only clinic targeting uninsured men in the US. The Center focuses on helping men stay healthy, which will help build healthier families.15
What should be done?
Heterosexual men are still in need of basic HIV/AIDS information. Programs are needed for heterosexual men that address their health and well-being and teach them how to advocate for their own health care. Programs also need to acknowledge that heterosexual men may engage in sex with men, and encourage safer sex in all sexual encounters. Finally, programs for heterosexual men need to be developed in conjunction with women, so that female partners' needs and concerns are incorporated.
Drug treatment and access to sterile syringes through needle exchange programs and pharmacy exchanges are crucial for heterosexual men. Incarcerated men need access to drug treatment, condoms, clean syringes, HIV prevention education and transitional case management to help ease risks both while incarcerated and upon release.
Heterosexual men need to take more responsibility for trying to stop the spread of HIV. Because men have not traditionally been involved in health care and prevention issues, training and support for heterosexual men will be necessary to ensure and sustain their involvement in HIV prevention.
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4. Wasserheit JN. Epidemiological synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases . Sexually Transmitted Diseases. 1992;19:61-77.
5. Sternberg S. 'Secret' bisexuality among Black men contributes to rising number of AIDS cases in Black women. USA Today. March 15, 2001.
6. Hammett TM, Harmon P, Maruschak L. 1996-1997 Update: HIV/AIDS, STDs and TB in correctional facilities. Abt Associates, Inc .: Cambridge, MA; 1999.
7. Sandman D, Simantov E, An C. O ut of Touch: American Men and the Health Care System . Published by The Commonwealth Fund. March 2000.
8. Fichtner RR, Wolitski RJ, Johnson WD, et al. Influence of perceived and assessed risk on STD clinic clients' acceptance of HIV testing, return for test results, and HIV serostatus. Psychology, Health & Medicine. 1996;1:83-98.
9. Israelski D, Gore-Felton G, Wood MJ, et al. Factors associated with keeping medical appointments in a public health AIDS clinic. Presented at the 8th International AIDS Conference, Durban, South Africa. Abst# WePeD4570.
10. Carter JA, McNair LD, Corbin WR. Gender differences related to heterosexual condom use: the influence of negotiation styles . Journal of Sex & Marital Therapy. 1999;25:217-225.
11. Parham TA, McDavis RJ. Black men, an endangered species: Who's really pulling the trigger? Journal of Counseling & Development. 1987;66:24-27.
12. Summerrise R, Wilson W. “The Black Print” model for recruitment of African-American males. Published by the Chicago, IL, Prevention Planning Group. 2000.
13. Kalichman SC, Cherry C, Brown-Sperling F. Effectiveness of a video-based motivational skills-building HIV risk-reduction intervention for inner-city African American men . Journal of Consulting and Clinical Psychology. 1999;67:959-966.
14. Summerrise R. Valuing the lives of men: HIV prevention for heterosexual men. Presented at the US Conference on AIDS, Atlanta, GA. October, 2000.
15.Sugg DK. A first for men: clinic opens in Baltimore . The Baltimore Sun. May 11, 2000.
*Le Penseur Youth Services, Chicago, IL; **CAPS
April 2001. Fact Sheet #22ER
Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to CAPS.firstname.lastname@example.org. © April 2001, University of California