Special Settings, Special Needs

Some circumstances place men at particularly high risk of contracting HIV. Men who migrate for work and live away from their wives and families may pay for sex and use substances, including alcohol, as a way to cope with the stress and loneliness of living away from home. Men living or working in all-male settings, such as the military, may be strongly influenced by a culture that reinforces risk-taking behaviour.

In some all-male institutions, men who normally prefer women as sex partners will have sex with fellow inmates. For one group of miners in South Africa, drinking and buying sex were the only "fun" available. The same men believed that the risk of HIV was small compared with the risk of death in the mines. Men in other high-risk or violent settings -- such as those living on the streets, those involved in drug-trafficking gangs or in a war setting -- may operate with a similar logic: "I'll probably die anyway, so why worry about AIDS?"

Men in the military are at increased risk of HIV and other STIs. Away from home and from their regular sex partners, sexual activity -- both consensual sex and rape -- may increase. Several studies confirm higher rates of HIV infection among military personnel: 22% of military personnel tested HIV positive in the Central African Republic (compared with 11% in the overall adult population). Unprotected sex between men in the military, generally hidden, may also contribute to HIV transmission.

The cross-border mobility of truck drivers, migrant workers and military personnel means that they sometimes play an important role in introducing HIV into an area. For men away from home, the limited choice of sex partners often includes sex workers, a small group who are liable to become infected through frequent and unprotected intercourse with their clients and in turn infect others in the community.

Millions of men worldwide are in jail -- at rates far higher than women. Here, sex takes place between prisoners and between prisoners and guards, or may occur in degrading conditions with the men's female partners or with sex workers. Some of this is coerced sex or rape and most of it is unprotected by condom use. Studies from Australia, Brazil, Canada, Costa Rica, Nigeria, the UK and Zambia show that between 6% and 70% of men in prison have sex with other men. Many prisoners, incarcerated for drug-related offences, continue to take and even inject drugs while in jail. As a result of both sexual and drug-related transmission, there are often high rates of HIV among prisoners. In France, inmates are 10 times more likely to be HIV-positive than the general population, while AIDS is responsible for half of all deaths in prisons in Brazil.

There have been several HIV prevention programmes in prisons, including condom distribution and the supply of bleach or sterilized needles for inmates who inject drugs. However, attempts to start such programmes have met with resistance either from prison authorities -- on the grounds that both intercourse and drug use are illegal in prison -- or from the public, who feel that prisoners do not "deserve" adequate or dignified living conditions. As a result, HIV spreads among prisoners while they are in jail, and to others in the community when the prisoners are released.

Male sex work is common in many countries, although it is often hidden and denied since most male sex workers have sex with other men. Some do have female clients, including "sugar mommies" -- older women offering cash or gifts for sex. Young male sex workers, like their female counterparts, often lack the power to negotiate safer sex, although male condom use may in theory be easier for a sex worker when his client is a woman. Experience from cities as diverse as Amsterdam, Berlin, Casablanca and Rio de Janeiro shows that young male sex workers can be successfully reached by programmes which offer them a range of confidential services, have staff who are open and sensitive to their needs, provide convenient drop-in spaces, and respect the culture of the street.

Special risks also face young people living on the streets. Sex, generally unprotected, can represent not just a rare source of pleasure but a means of survival, or of dominating girls or other boys. Studies in Brazil found around one-fifth of such young people to have a sexually transmitted infection. High rates of substance use -- as a way of enduring life on the streets -- can also inhibit safer sex practices.

In addition to these specific risk settings, poverty and unemployment may increase men's sexual risk-taking as a way of compensating for their perceived loss of manhood. Research in some rural areas of Kenya and Tanzania finds that when men become unemployed and hence lose their status as providers, they are more likely to have sex with sex workers or other partners to feel "more like men."

In addition to the HIV prevention programmes for prisoners and male sex workers described above, successful initiatives have been directed at other men at special risk, such as long distance truck drivers in Africa and India. In each case, however, the number of men reached is only a tiny proportion of those who need information and help.