Objective Two:
To encourage men to take care of themselves, their partners and families

• Objective 2.1: Encourage men to take care of themselves

• Objective 2.2: Encourage men to take more care of their partners and their families

• Objective 2.3: Provide good-quality education in sexual health, HIV/AIDS and life skills for boys -- and girls -- in and out of schools

• Objective 2.4: Educate men about their roles as perpetrators and subjects of violence, and their responsibility to stop violence
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• Objective 2.5: Develop HIV/AIDS programmes for men at particular risk

Objective 2.1: Encourage men to take care of themselves

Except in a handful of countries, men have a lower life expectancy at birth and higher death rates during adulthood than women. Healthy lifestyles and timely medical intervention can prevent or cure many of the health problems that men face. However, many boys and men may see themselves as somehow invulnerable to risks or illnesses, and postpone seeking health care.

Generally, adolescence and young adulthood are times of good health. However, during these stages of their lives many young men and women do require access to health care. Many young women are treated for sexually transmitted infections, sometimes as a consequence of sexual coercion or rape. Rather than sexually transmitted infections, trauma due to traffic accidents or physical violence at the hands of other men are more common among young men. The above emotional and physical traumas among young women and men often result from a 'masculine' desire to prove oneself or take risks.

Most societies allot the role of breadwinner to men and confer special privileges on both men and boys compared to women and girls. However, manhood brings with it a mix of personal costs as well as benefits -- costs which are reflected in men's mental and physical health. In many societies, men are conditioned not to express emotions, to maintain formal relationships with their children, to use violence to resolve conflicts and maintain "honour", and to work outside the home from an early age. In this context, it is worth noting that suicide worldwide is one of the three leading causes of death for adolescents, with three times as many boys as girls killing themselves. In some developed countries, the risk is tripled yet again among young gay men.

Men need to accept that their health is important, for their own well-being as well as those who are dependent on them. This is true for all men irrespective of HIV status. HIV infection is a heavy burden to bear, mentally, physically and emotionally. But even in the absence of antiretroviral therapy, an individual can, on average, live for over nine years following HIV infection before falling seriously ill and survive up to a year beyond that. The bottom line is: men do have some control over their health and the goal is to convince them of this.

Ideas for Actions

• Pay greater attention to boys' health as part of school health education programmes.
• Train health workers to better understand the special health needs of boys and men.
• Train health workers to pay greater attention to the mental health of men.
• Design easy-to-understand information, education, and communication (IEC) materials for boys and men focusing on their common concerns and health problems.
• Create pocket-sized cards entitled, "Know Your Responsibilities and Rights" that carry information for boys on one side and girls on the other and distribute to schoolchildren.
• Advocate for culture-specific research on social and economic factors in relation to 'masculinity'; to find out more about the pressures on men to behave in particular ways.

Objective 2.2: Encourage men to take more care of their partners and their families

In most societies, men are expected to provide for their female partners and children. It is true that some men are abusive or fail to provide for their families, while others provide merely financial support. However, it is increasingly recognized that a man's self-worth is enhanced, not compromised, by actively caring for his partner's and children's well-being.

Men who have emotional and sexual bonds with other men can also provide strong support for each other, although this is more difficult in societies where such relationships are illegal or not respected. It is to be noted that in many countries, the first AIDS care associations were established by gay men to provide support for each other.

While we obviously care more for those with whom we have strong emotional bonds, care can also be extended to partners in casual sex encounters or those with whom injecting needles are shared. If we expect others not to infect us, we need to make efforts not to infect others.

Men can take care of their partners and families in many ways: they can protect them by not bringing HIV into the household -- by not having sexual relations or sharing injecting equipment with others, or by always using condoms outside of the relationship and using only clean needles and syringes. Mother-to-child transmission is by far the most common cause of HIV infection in young children. In most cases, the mother acquired HIV from the father of her child. Raising awareness of mother-to-child transmission of HIV can play a major role in protecting men, their partners and their future children.

And men can be actively involved in the raising of their children, offering options to them on how to respond to sexual advances, discussing love and relationships, and act as a positive role model for their sons.

Men can provide support for partners and children who are ill -- by ensuring a steady income whenever possible; by encouraging sick partners to rest and taking on the tasks that they would otherwise perform, such as fetching water or cooking meals; and by providing their children with love and affection.

Men who have contracted HIV can plan for the future -- by leaving savings or income from land or other sources to ensure the family's well-being. In developing countries, most HIV-positive people are already poor. This combined with social and cultural practices, nearly always result in the assets of a family being used to cover the costs of care in the last years of life or to substitute for lost income. Even so, men should make whatever provisions possible.

Ideas for Actions

• Establish programmes that encourage young, unmarried men to understand their roles as future parents and prepare them to be involved in parenthood, promoting planned fatherhood as a masculine ideal.
• Provide for men-only sessions in family welfare / reproductive health / sexually transmitted infection clinics. Gain the support of local community leaders to encourage men to attend.
• Arrange counselling for couples who are considering having children and/or worried about their HIV-status.
• Educate men on their potential role in, and responsibility for, HIV transmission to their children prior to and during, their partner's pregnancy.
• Promote access to high-quality voluntary testing and counselling for men and women before and during pregnancy.
• Bring men together to talk about their concerns regarding care for their families and help them develop the skills to talk to -- and listen to -- their partners and children.
• Support organizations of people living with HIV/AIDS and other groups that can provide support for those infected as well as for those caring for HIV-positive people.
• Hold experience-sharing meetings where people with HIV talk with others about how they care for their families.
• Use "agony" columns in newspapers to answer questions from men wanting to become more involved in care for their families.
• Work with writers for radio and TV soap operas to integrate examples of caring men into their story lines.
• Encourage male celebrities and sportsmen to talk about their caring relationships with their partners and children.
• Use the Internet to promote men's involvement with their families by creating attractive sites that promote men's involvement with their families.
• Assist HIV-positive men or those affected by HIV to plan for the future care of their children.
• Help men and women with HIV to communicate their serostatus to their partners.

Objective 2.3 Provide good-quality education on sexual health, HIV/AIDS and life skills for boys -- and girls -- in and out of schools

A first step in changing men's attitudes towards seeking health care is educating young people as to its benefits.

Some people fear that educating young people about sex will encourage promiscuity. However, evidence shows that good-quality sex education can lower levels of sexual risk-taking and delay first sex. Sex education is most effective when given before young people begin their sexual lives. Well-planned sex education can help reduce the risk of contracting sexually transmitted infections, including HIV, and unwanted pregnancy.

While many boys and girls feel pressured to have sex, most are poorly informed about sexuality and reproduction. Parents need to talk more with their children about sex, sexuality and gender roles. Boys need to be taught that responsible sexual behaviour is a positive aspect of masculinity, and both boys and girls should be offered the chance to acquire the life skills needed to refuse sex or negotiate safer sex.

Apart from the family, there are other valuable sources of information and support for boys and girls. Teachers can provide information on pregnancy and sexually transmitted infections and help young people acquire useful life skills. Schools too can foster respect for all communities, equality between men and women and promote human rights.

Peer education can be an effective way of enabling frank discussions between people of similar age and backgrounds. Boys and girls can be trained as educators to inform and influence the behaviour of their peers.

Health care providers often require training to be able to discuss sexual health, HIV and life skills with boys and girls. An open and trusting relationship between doctors, nurses and young patients can be the beginning of building life long trust and communication -- the basis for medical care and support.

Men who are HIV-positive and are willing to speak openly about this can be a powerful force for change. From public figures such as Philly Lutaaya (a Ugandan singer), Freddie Mercury (a British singer), Magic Johnson (an American basketball player), Mr. Justice Edwin Cameron (a Judge of the High Court of South Africa) and Rudy Galindo (an American national figure skating champion) to unknown individuals living quietly but openly in towns and villages, men with HIV can and do lead fulfilling and exemplary lives.

Children and young people who do not attend school, who live on the streets or work from a tender age can be particularly vulnerable to HIV infection. Over a hundred million children, the majority of whom are from developing countries, lack access to primary education. They urgently need information on sexual health and HIV/AIDS and the skills with which to protect themselves from exploitation and abuse.

Ideas for Actions

• Train and support parents to talk to children about sex.
• Promote positive male role models in the youth media.
• Promote peer education, in a variety of settings, as a cost-effective and efficient means of education on sexual health and HIV education.
• Train boys and men as peer educators in life skills, sexual health, and AIDS education.
• Integrate life skills, sexual health and HIV/AIDS education into all curricula from primary school to tertiary education. Develop such programmes in consultation with parents, teachers and students.
• Ask people living with HIV/AIDS to talk to young people in schools and in community forums about their experiences of life before and after their HIV diagnosis.
• Train community workers to use techniques such as games and role-plays to teach young people about life skills, sexual health, and HIV/AIDS.

Objective 2.4: Educate men about their roles as perpetrators and subjects of violence, and their responsibility to stop violence

Health statistics from many parts of world confirm that injuries resulting from violence are among the chief causes of mortality and morbidity among young men.

In addition to the violence that men perpetrate on each other, men inflict violence on women, some of it sexual. 35 studies from a variety of countries in Africa, Asia, Latin America, Europe and North America found that one-quarter to more than half of the women reported having been physically abused by a present or former partner. Sexually aggressive young men were themselves more likely to have been sexually abused, to have witnessed abuse of a family member, to have a sexually transmitted infection, and to have used drugs or alcohol.

Sexual violence may take place in relationships. A recent study in Northern India found that 46% of men reported abusing their wives, and that these men were more likely to engage in extramarital sex and have a sexually transmitted infection than non-abusive men.

Violence may also take place during dating. Studies among high school and college students in New Zealand and the United States. found that between 20 and 59 % of males and females said they had experienced physical aggression during a dating relationship. While nearly equal numbers of males and females reported that they had been subjected to violence, male violence against women tended to be more severe, and men tended to initiate this violence.

There are many difficulties in documenting sexual assault and violence by boys and men. People subjected to sexual violence are often afraid to report violations. Societal norms may portray sexual coercion as part of boys' normal sexual behaviour. For example, a widely publicized event in Kenya in 1991 in which 71 young women were raped and 19 died in a group attack from their male classmates, reportedly elicited the comment "boys will be boys".

Male violence drives the HIV epidemic in a number of ways. Rape and sexual abuse may place women and children at risk of contracting HIV. Sexual violence and mass migration are often the results of war, and not only are families split up, and husbands and wives separated, but in refugee camps and elsewhere women may become the subject of unwanted demands for sex, or may have to trade sex in order to survive. Innumerable instances of rape by members of the armed forces and paramilitary groups have been documented, and there is strong evidence that sexual violence, or the threat of it, is used as a means of terrorizing or subjugating both women and other men.

In addition to the possibility of HIV infection through sexual violence, other health consequences include physical injury, sexually transmitted infections and unwanted pregnancy. Some studies have shown that men and women who had been raped or forced to have sex during their childhood or adolescence were twice as likely to have multiple partners in a single year and to engage in casual sex. They were also four times as likely to be sex workers, and women who had been subjected to childhood sexual violence were twice as likely to be heavy consumers of alcohol and nearly three times as likely to become pregnant before the age of 18.

Young men are more frequently studied as perpetrators rather than as subjects of violence. However, some research shows that young men are also subjected to violence. And when they are allowed to do so, young men express their fear of the potential for violence within themselves, the threat of violence from other men and of the violence inflicted on them.

Ideas for Actions

• Develop programmes that offer young men constructive ways of resolving conflicts, developing their identities and expressing their emotions.
• Develop programmes that discuss violence within relationships or during dating.
• Highlight sexual violence as a cause of HIV transmission.
• Highlight the link between sexual violence and the future behaviour of people subjected to violence and their increased risk of HIV infection.
• Offer opportunities to discuss the violence boys witness and to reduce the stress and consequences associated with being a subject of violence.
• Establish programmes in settings where violent and delinquent behaviour by boys is prevalent and sensitize boys from an early age.
• Find ways of engaging young men positively in their community, family and peer groups.
• Educate parents, teachers, health personnel and other youth-serving professionals about the origins of violent behaviour among boys, helping them to effectively tackle the boys rather than responding in punitive ways.

Objective 2.5: Develop HIV/AIDS programmes for men at particular risk

A number of settings present boys and men with a higher than average risk of contracting HIV. These include:

• Men in prisons may contract HIV through shared injecting equipment, consensual or forced sex with other prisoners or staff (usually male) or with visitors from outside (usually female).
• Men in the military, who may have sex with a relatively small group of women -- a situation which encourages rapid transmission of HIV -- and/or who may have sex with other men may contract HIV. There have been reports from some countries of high rates of HIV infection among military forces.
• Sailors and fishermen who spend weeks or months at sea with sex workers popularly known as "hostesses".
• Men and boys who sell sex or exchange sex for food or shelter. Male sex workers
• Homeless boys who have sex with other street children or who exchange sex for a meal, a bed or some emotional comfort, no matter how transient.
• Mostly underage boys who drop out of school because of poverty and are often employed in jobs where the working conditions are harsh.
• Migrants who have sex with men or women as a means of alleviating loneliness and stress.
• Boys in care institutions or boarding schools who have forced or consensual sex with other boys or staff members.

Special settings offer special challenges that require suitable responses. For example, those in charge of such settings, e.g. military leaders, governors of prisoner, boat owners, etc., are often resistant to the idea of change. In situations where forced sex is common, it is practically impossible to institute safer sex. Nonetheless, persistence can pay dividends; innovative HIV prevention programmes are now in place in the Zambian armed forces, prisons in Ukraine and for male sex workers in Morocco, Costa Rica and Brazil.

Ideas for Actions

• Use the success stories about prison-based HIV interventions to explain to prison warders, administrators and the government that the provision of sterile injecting equipment and condoms have not posed a threat to the safety of prison warders.
• Initiate debate on the human rights of prisoners (i.e. recognizing that people are in jail for a crime and their incarceration should not jeopardize their rights to health, security of the person, equality before the law and freedom from inhuman and degrading treatment).
• Promote debate on the need for HIV prevention programmes in prison that are rooted in the realities of prison life.
• Facilitate interventions approved by prison administrators and government and run by community organizations inside prisons. These should be sensitive to the specific needs of prisoners and their sexual and drug-injecting partners both within and outside of prison. Promote safer sex and ration out sterile injecting equipment and condoms to inmates or provide them in places where people can pick them up in private.
• Provide treatment for sexually transmitted infections for prisoners alongside counselling and voluntary testing services, and regular encouragement to use the services.
• Explain safer sex and provide sterile injecting equipment and condoms to boys in institutional care either as a ration, or in places where people can pick them up in private.
• Provide treatment for sexually transmitted infections for boys in institutional care, alongside counselling and voluntary testing services with regular encouragement to use the services.
• Request high-ranking military officers to take charge of implementing HIV prevention programmes which address the specific risks faced by members of the armed forces, such as sex with sex workers, rape and sex between men.
• Promote condom distribution among soldiers as well as voluntary and confidential counselling and testing for HIV. For example, the United Nations recently decided to issue all its peacekeeping personnel with one condom per day.
• Undertake peer education in workplaces where young boys may frequently be found, such as motorcycle stands, construction sites, gas stations, etc.
• Translate HIV prevention material into the languages used by migrants and ethnic minorities, and distribute it to migrant organizations, health service providers, NGOs, lawyers and others who come into contact with illegal migrants.
• Promote outreach and peer education programmes for immigrants and ethnic minority communities.
• Institute or support already existing programmes or organizations which work with migrants, itinerant workers, male sex workers and the homeless to include HIV prevention, care and support within their work.
• Provide HIV-related information, health services and prevention materials to boys in boarding schools, alongside the opportunity to talk about sex, sexuality and drug use.