Objective 1.1: Motivate men and women to talk openly about sex, sexuality and HIV/AIDS

Rather than admitting to sexual ignorance or perceived inadequacy, men frequently find themselves having to make false sexual claims and repeating the myths surrounding sex, in order to appear as "real men" in the eyes of their peers. Men's discussions about their sexual experiences rarely touch upon the subject of the sexual needs of their partners. Men must learn to talk about their sexual needs rather than their sexual prowess to build respect for both themselves and their sexual partners.

Popular belief holds that the 'male sex drive' is 'boundless and irrepressible', and in some parts of the world, having a sexually transmitted infection is considered a badge of honour that confirms one's manhood. The myth of male superiority that is deeply ingrained in many societies inadvertently assists the transmission of HIV.

In many societies, cultural barriers can inhibit public discussions of sexuality and therefore prevent a better understanding of male and female sexuality and of men's and women's needs. This silence also perpetuates stigma and discrimination against men who have sex with men, ignores women's right to sexual pleasure and hampers HIV prevention.

Research in many parts of the world suggests that men tend to have more sexual partners during their lifetime than women. A double standard of sexual morality is the norm in many societies. For example, many cultures expect women to preserve their virginity until marriage. Young men, on the other hand, are encouraged to gain sexual experience. Indeed, having many sexual relationships may make a man popular in the eyes of his peers.

In most societies women have less access to health care, education and employment. Their unequal situation is reinforced in many societies by the double standards of sexual morality. These ensure that women can be viewed as creatures that lead men 'astray'. Sometimes, merely dressing in an alluring fashion or appearing attractive suffices to earn a women the label of 'sexually promiscuous'. When women are subjected to violence or sexual abuse, it is conveniently said that women 'get what they deserve'. A key reason for such misconceptions is that men may not understand the true nature of their own sexuality or that of women.

Many cultures throughout the world adhere to age-old traditional practices wherein women serve to provide sexual pleasure to men. One such practice is "dry" sex where tobacco, herbs, bleach or other drying agents are used to dry out the vagina to increase penile friction. This may cause lesions in the vaginal walls, putting women at increased risk of HIV transmission during unprotected sex. Dry sex is still practised in parts of East and Southern Africa. Another traditional practice, common in some African communities, is for a younger brother to marry his sister-in-law if his elder brother dies. Originally, such practices evolved to protect the family and the tribe. However, today they can cause further HIV transmission within the family circle.

In many cultures, fathering a child is regarded as a proof of masculinity. This belief virtually proscribes condom use, providing increased opportunities for HIV infection within the family and possibly to the next generation through mother-to-child transmission.

In many societies having sex with a younger girl is believed to increase virility, and is seen as a risk minimization strategy by older men or, as in some societies, taking a girl's virginity is thought to be a cure for HIV. Yet older, sexually active men are more likely to be HIV-infected. While trying to decrease their risk of 'becoming HIV-infected', they are in fact putting young girls at risk of HIV, other sexually transmitted diseases and pregnancy.

HIV compels people to face the consequences of their actions, particularly when acquired through sexual activity outside relationships thought to be monogamous. Because of the serious, long-term consequences of risky sexual behaviour, it is important for sexual partners to learn to talk to each other about sex, particularly safer sex. Of course, there are social and cultural barriers to discussing sex and HIV. However, when sexual partners encourage each other to be truthful in exchanging experiences and fears, they may find ways of protecting each other from HIV.

While sexual abstinence is the surest way of avoiding HIV infection through sex, it may not be the preferred option for many people. However, there are always other safer sexual options available including fidelity, non-penetrative sex, and consistent condom use outside of and/or within a relationship. In long-term relationships, many couples are increasingly seeking voluntary counselling and testing to ascertain each other's sero status and to decide if they can enjoy sex without condoms within the relationship. However, it must be remembered that this option requires considerable trust, consistency and commitment, since remaining faithful or practising only safer sex outside of the relationship is something often promised but later forgotten.

Many men are happy to talk about sex when they can ask questions without fear of scorn or censure. Men also want to find out about HIV and other sexually transmitted diseases. Young men and adolescent boys in particular, often have several questions and concerns about their relationships, their own anatomy and that of their partners.

Policy-makers have a duty to create the social environment in which sex and sexuality can be spoken about. Changing the social climate is necessary to changing the course of the HIV epidemic. HIV challenges us all in how we live. Policy-makers, like all of us, need the courage to confront their own behaviours and the social settings, which allow the epidemic to spread.

The more men can talk frankly about sex, feel respected and have their questions answered, the more they are likely to protect themselves and their sexual partners. The challenge for those working with men is to provide appropriate opportunities for men and boys to talk, listen and learn about sex.

Ideas for Actions

• Help parents to discuss drug and alcohol use, sexuality, and HIV with their children.
• Support meetings of village elders to discuss men's behaviour.
• Use community forums to discuss HIV/AIDS and related issues.
• Train peer educators to gain the confidence of, and talk to, men in bars and other places where men get together socially.
• Train and support teachers to discuss sexuality and reproductive health in the classroom.
• Encourage small group interaction and the exchange of experiences, among people of different sexual orientations.
• Work with religious leaders to include AIDS education in schools and in community activities.
• Urge male celebrities to speak out openly about sexuality and the need for men to change their sexual behaviour, and provide them with simple messages on these issues, to be used in public forums or media interviews.
• Initiate awards for boys' clubs or youth clubs as incentives for boys to teach each other how best to respond to HIV/AIDS.
• Encourage boys and men to make their views on sex and HIV known through radio and television phone-ins and letter writing.
• Train doctors and health workers to talk with and listen to their male patients about sexual behaviour, sexuality and safer sex.
• Hold meetings of small groups of men in the workplace so that HIV prevention can be discussed in depth.
• Explore ways of introducing discussions on HIV/AIDS in groups and organizations which to date have not tackled HIV.
• Brief journalists on issues related to HIV/AIDS, such as sexuality, care and support and prevention.
• Work with journalists and editors to include AIDS-related topics in radio and TV programmes, and in newspapers and magazine articles.
• Use peer educators to host Internet chat rooms to discuss boys' and men's concerns regarding AIDS and other matters relating to sex.
• Devise Internet sites and banners that encourage men to play a greater role in preventing the spread of HIV.
• Integrate messages on men's behaviour and HIV into politicians' and leaders' speeches.
• Organize meetings with policy-makers to discuss the role of men in the HIV/AIDS epidemic -- while being sensitive to the concerns of policy-makers as individuals as well as public leaders.
• Promote discussion of the role of traditional practices in the transmission of HIV.
• Promote discussion of traditional sexual practices and women's sexual fulfillment.
• Promote voluntary counselling and HIV testing before and during pregnancy.

Objective 1.2 Motivate men and women to talk openly about men who have sex with men (MSM) and HIV/AIDS

Men have sex with other men for many reasons. Sometimes for pleasure, for economic reasons, under compulsion, from lack of availability of women, or for a combination of the above reasons. Many men who have sex with men also have sex with women -- for pleasure, from a sense of duty, from self denial or to hide their desires from others.

The number of men -- and boys -- who have sex with other men is not known. Similarly, the number of HIV infections worldwide that have been caused by sex between men is also unclear. HIV prevention for men who have sex with men is essential, both to protect themselves and their female partners if any.

Hostility towards and misconceptions about sex between men have resulted in inadequate HIV prevention measures in many countries. Some governments refuse to acknowledge that sex between men takes place. Others have criminalized anal sex. And some governments refuse to support prevention programmes for men who have sex with men. As a result these men and their partners are at an increased risk of HIV infection.

In many countries, men who have sex with men are not socially accepted. To hide their sexual orientation, such men have clandestine sexual alliances or rushed sexual encounters with other men who have sex with men. During such encounters, there is little time for, or interest in negotiating condom use. Many such men also have unprotected sex with women either to satisfy their marital obligations, or to mask that they have other sexual partners. The risk of HIV transmission to both men and women is high in such situations.

In all male settings such as the military, prisons, boarding schools and institutional care, men may also have sex with one another. While outside these settings such men generally have sex with women, the nature of their situation means that the only forms of sexual expression available are masturbation or sex with other men. Unprotected sex between these men poses a risk of HIV and other sexually transmitted infections being spread within the population and to female partners outside the institution.

Ideas for Actions

• Train peer educators to talk to men who have sex with men about HIV prevention in bars and other places where they meet socially or for sex.
• Discuss the links between drug and alcohol use and sex between men.
• Urge male celebrities to speak openly about men who have sex with men and the need for men to change their behaviour; and provide the celebrities with simple messages on these topics to be used in public forums or media interviews.
• Encourage open discussions about sex between men in the community as well as in male-only institutions, including discussions on the possibility of HIV transmission between men within and outside these environments.
• Help parents better understand the development and psychology of their children and young people.
• Teach parents how to adjust to the development of their child's sexuality.
• Train doctors to talk with and listen to their male patients about sexual behaviour, sexuality and safer sex.
• Invite representatives of groups of men who have sex with men to talk to AIDS service organizations and in other forums where HIV prevention is discussed.
• Use the Internet to find and share examples of successful AIDS prevention programmes for men who have sex with men.
• Include a component on men who have sex with men in the planning and implementation of national AIDS programmes.

Objective 1.3 Motivate men and women to talk openly about alcohol, drug use and HIV/AIDS

Generally, men are more likely than women to use alcohol and illegal drugs since in many societies it is culturally and socially more acceptable for them to do so. Yet, as cultural and social norms change, the gap between the numbers of men and women who use substances is narrowing. For example, in Australia a New South Wales school-based survey found that more young women than young men are using heroin and cannabis.

Men's use of alcohol and other substances may be associated with violence towards others and/or an increased risk of unsafe sex with a regular or casual partner. The use of other substances, such as ecstasy, is not associated with violence but can lower inhibitions and may be associated with unsafe sex.

Injecting drug use is directly responsible for over 5% of HIV infections worldwide. Of the estimated 6-7 million individuals around the world who inject drugs, four-fifths are men.

Discussions about substance use, dependence, and the underlying reasons for drug use are often inhibited, as many of the substances discussed are illegal. Similarly, talking about alcohol-related violence is often taboo. Men and women need more opportunities to discuss substance use in relation to their own lives and the possibility of an increased risk of HIV infection.

Prevention programmes aimed at reducing men's dependence on alcohol and other substances face a number of difficulties.

For example, alcohol is socially accepted in many parts of the world. In rural areas in particular, gatherings where alcohol is readily available may be one of the few available forms of pleasure and entertainment.

Among those who inject drugs, rituals can evolve in which men take on the controlling role in the drug-taking behaviour. Often men have control of the needle and syringe, and a 'pecking order' is established for injection. This may involve the lead man injecting first, followed by other men and eventually women. In such a situation it is those who inject last who are at the greatest risk of HIV infection. It is essential in designing interventions to understand these practices.

The illegality of some substances makes them attractive to many young men. Advocating and strengthening HIV prevention programmes among substance users is acknowledged as the best approach to reduce harm to individuals and communities. A comprehensive approach to prevention and care includes educating injectors and their sex partners about HIV risks and safe practices; making drug treatment programmes available; providing access to counselling, to care and support and to other health services; providing condoms and exchanging used injecting equipment for sterile or 'clean' equipment; increasing access to needle-syringe exchange programmes through pharmacies and medical services combined with safe disposal programmes; and outreach, peer education and networking activities

Ideas for Actions

• Target men with messages about alcohol and drug use, on telephone cards, matchbooks etc.
• Raise the issue of alcohol use at village meetings; encourage community leaders to promote non-alcoholic beverages at formal and other gatherings.
• Publicize Internet chat rooms where men with substance dependency problems can share concerns in a safe and anonymous environment.
• Train doctors and health workers to talk with their patients about substance use including drugs that are injected, sexual behaviour and safer sex.
• Negotiate with the authorities "safe spaces" in the community where drug injectors can learn about HIV prevention from peer educators or medical practitioners.
• Work with local communities, including the drug-using community, to explore effective ways of running needle exchange programmes that will also provide information, counselling, condoms, and medical care.
• Work with local communities on the introduction of needle-syringe programmes through pharmacies and medical services in conjunction with safe disposal programmes.
• Target peer education through newsletters.
• Mobilize injecting substance user associations to advocate for needle exchange programmes, protection of their human rights, and access to treatment.
• Mobilize injecting substance user associations to negotiate with police and policy-makers over issues of policing and the situation of vulnerable populations such as sex workers.
• Improve access to drug treatment programmes.
• Generate public debate about the relative merits of harm reduction and demand reduction.
• Include a component on injecting drug use and users in the planning and implementation of national AIDS programmes.