Are heterosexual men reached?
Yes and no. Many prevention programs in the U.S. have addressed the drug-using risks of heterosexual men, but few have addressed their sexual behavior risks. In the U.S., women have been the primary focus of sexual behavior change among heterosexuals. This approach fails to take into account gender and power imbalances, and does not encourage men to take responsibility for their own health or the health of their partners and family.
In the U.S., new AIDS cases are increasing most rapidly among people who were infected through injecting drug use (IDU) and heterosexual contact. The rise in IDU infections in heterosexual men has led to the rise in heterosexual 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.
What puts men at risk?
Injection drug use poses the highest risk to heterosexual men. Use of other non-injected substances such as crack cocaine and alcohol can increase sexual risk-taking and risk of HIV infection. A survey of heterosexuals in alcohol treatment programs in San Francisco, California, found HIV infection rates of 3 percent for men. This was considerably higher than rates of 0.5 percent found in a general population survey.2
Men in certain settings are at greater risk. In the U.S., 90 percent of prisoners are men. In 1994, AIDS cases for people in state or federal prisons reached 518 for every 100,000, as compared to 41 for every 100,000 for the general population of the U.S.3 Injection drug use, other illicit drug use and unprotected sex with other men are all risk behaviors for HIV in prison or jail.
A survey of active duty men in the U.S. Army found that heterosexual men who had sex with prostitutes had increased numbers of female partners, had non-steady partners, or had sex on the first day of acquaintance were at highest risk for HIV.4
What makes prevention difficult?
Safer sex guidelines can be at odds with some perceived male roles.5 For example, masculinity and sexuality are sometimes defined by having sex with multiple partners, in contrast to safer sex guidelines that call for reducing numbers of partners. A study of HIV positive male and female heterosexuals found that before diagnosis of positivity, men had far fewer monogamous relationships than women (4 percent vs. 55 percent). After diagnosis, none of the women, but 14 percent of men reported having multiple partners.6
Communication between men and women can be difficult, especially regarding condom use, disclosure of risk behaviors or HIV status. Traditional social and cultural gender roles in the U.S. often portray women, and not men, as the “communicator” in relationships, which might serve to relieve men of responsibility for communication.5 In 1995, over half of all female AIDS cases occurring via heterosexual contact were a result of sex with a male partner whose HIV risk was either unknown or unreported, showing that women are often unaware of their partner’s HIV risk.1
Male violence and sexual coercion can be a barrier to safer sex. For example, a survey of Latino heterosexual men in the U.S. found that traditional Latino gender role beliefs impede condom use by encouraging sexual coercion, lowering sexual comfort and interfering with self-efficacy to use condoms.7
IDUs often lack access to sterile syringes via needle exchange/distribution programs or pharmacy sales. Access to drug treatment programs is also insufficient — at any given time, only 15 percent of IDUs in the U.S. are in treatment programs.8