Incursions from the epicentre: Southern theory, social science, and the global HIV research domain.

Research about HIV constitutes a global domain of academic knowledge. The patterns that structure this domain reflect inequalities in the production and dissemination of knowledge, as well as broader inequalities in geopolitics. Conventional metrics for assessing the value and impact of academic research reveal that "Northern" research remains dominant, while "Southern" research remains peripheral. Southern theory provides a framework for greater critical engagement with knowledge produced by researchers within the global South. With a focus on HIV social science, we show that investigators working in and from Africa have produced and disseminated knowledge fundamental to the global domain of HIV research, and argue that their epistemological contribution may be understood within the framework of Southern theory. Through repurposing a bibliometrical measure of citation count, we constitute a new archive of highly cited social science research. With a focus on South Africa, we situate this archive within changing historical contexts, connecting research findings to developments in medicine, health sciences and politics. We focus on two key themes in the evolution of HIV knowledge: (1) the significance of context and locality - the "setting" of HIV research; and (2) sex, race and risk - changing ideas about the social determinants of HIV transmission.

Re-making the global economy of knowledge: do new fields of research change the structure of North-South relations?

How is global-North predominance in the making of organized knowledge affected by the rise of new domains of research? This question is examined empirically in three interdisciplinary areas - climate change, HIV-AIDS, and gender studies - through interviews with 70 researchers in Southern-tier countries Brazil, South Africa and Australia. The study found that the centrality of the North was reinstituted as these domains came into existence, through resource inequalities, workforce mechanisms, and intellectual framing. Yet there are tensions in the global economy of knowledge, around workforce formation, hierarchies of disciplines, neoliberal management strategies, and mismatches with social need. Intellectual workers in the Southern tier have built significant research centres, workforces and some distinctive knowledge projects. These create wider possibilities of change in the global structure of organized knowledge production.

Hegemonic masculinity: combining theory and practice in gender interventions.

The concept of hegemonic masculinity has been used in gender studies since the early-1980s to explain men's power over women. Stressing the legitimating power of consent (rather than crude physical or political power to ensure submission), it has been used to explain men's health behaviours and the use of violence. Gender activists and others seeking to change men's relations with women have mobilised the concept of hegemonic masculinity in interventions, but the links between gender theory and activism have often not been explored. The translation of 'hegemonic masculinity' into interventions is little examined. We show how, in South Africa and Sweden, the concept has been used to inform theoretically-based gender interventions and to ensure that men are brought into broader social efforts to build gender equity. We discuss the practical translational challenges of using gender theory broadly, and hegemonic masculinity in particular, in a Swedish case study, of the intervention Machofabriken [The Macho Factory], and illustrate how the concept is brought to life in this activist work with men. The concept has considerable practical application in developing a sustainable praxis of theoretically grounded interventions that are more likely to have enduring effect, but evaluating broader societal change in hegemonic masculinity remains an enduring challenge.

Prevalence of consensual male-male sex and sexual violence, and associations with HIV in South Africa: a population-based cross-sectional study.

BACKGROUND: In sub-Saharan Africa the population prevalence of men who have sex with men (MSM) is unknown, as is the population prevalence of male-on-male sexual violence, and whether male-on-male sexual violence may relate to HIV risk. This paper describes lifetime prevalence of consensual male-male sexual behavior and male-on-male sexual violence (victimization and perpetration) in two South African provinces, socio-demographic factors associated with these experiences, and associations with HIV serostatus. METHODS AND FINDINGS: In a cross-sectional study conducted in 2008, men aged 18-49 y from randomly selected households in the Eastern Cape and KwaZulu-Natal provinces provided anonymous survey data and dried blood spots for HIV serostatus assessment. Interviews were completed in 1,737 of 2,298 (75.6%) of enumerated and eligible households. From these households, 1,705 men (97.1%) provided data on lifetime history of same-sex experiences, and 1,220 (70.2%) also provided dried blood spots for HIV testing. 5.4% (n = 92) of participants reported a lifetime history of any consensual sexual activity with another man; 9.6% (n = 164) reported any sexual victimization by a man, and 3.0% (n = 51) reported perpetrating sexual violence against another man. 85.0% (n = 79) of men with a history of consensual sex with men reported having a current female partner, and 27.7% (n = 26) reported having a current male partner. Of the latter, 80.6% (n = 21/26) also reported having a female partner. Men reporting a history of consensual male-male sexual behavior are more likely to have been a victim of male-on-male sexual violence (adjusted odds ratio [aOR] = 7.24; 95% CI 4.26-12.3), and to have perpetrated sexual violence against another man (aOR = 3.10; 95% CI 1.22-7.90). Men reporting consensual oral/anal sex with a man were more likely to be HIV+ than men with no such history (aOR = 3.11; 95% CI 1.24-7.80). Men who had raped a man were more likely to be HIV+ than non-perpetrators (aOR = 3.58; 95% CI 1.17-10.9). CONCLUSIONS: In this sample, one in 20 men (5.4%) reported lifetime consensual sexual contact with a man, while about one in ten (9.6%) reported experience of male-on-male sexual violence victimization. Men who reported having had sex with men were more likely to be HIV+, as were men who reported perpetrating sexual violence towards other men. Whilst there was no direct measure of male-female concurrency (having overlapping sexual relationships with men and women), the data suggest that this may have been common. These findings suggest that HIV prevention messages regarding male-male sex in South Africa should be mainstreamed with prevention messages for the general population, and sexual health interventions and HIV prevention interventions for South African men should explicitly address male-on-male sexual violence.

Transactional relationships and sex with a woman in prostitution: prevalence and patterns in a representative sample of South African men.

BACKGROUND: Sex motivated by economic exchange is a public health concern as a driver of the Sub-Saharan African HIV epidemic. We describe patterns of engagement in transactional sexual relationships and sex with women in prostitution of South African men, and suggest interpretations that advance our understanding of the phenomenon. METHODS: Cross-sectional study with a randomly-selected sample of 1645 sexually active men aged 18-49 years who completed interviews in a household study and were asked whether they had had sex with a woman in prostitution, or had had a relationship or sex they took to be motivated by the expectation of material gain (transactional sex). RESULTS: 18% of men had ever had sex with a woman in prostitution, 66% at least one type of transactional sexual relationship, only 30% of men had done neither. Most men had had a transactional relationship/sex with a main partner (58% of all men), 42% with a concurrent partner (or makhwapheni) and 44% with a once off partner, and there was almost no difference in reports of what was provided to women of different partner types. The majority of men distinguished the two types of sexual relationships and even among men who had once-off transactional sex and gave cash (n = 314), few (34%) reported that they had had sex with a 'prostitute'. Transactional sex was more common among men aged 25-34 years, less educated men and low income earners rather than those with none or higher income. Having had sex with a woman in prostitution varied little between social and demographic categories, but was less common among the unwaged or very low earners. CONCLUSIONS: The notion of 'transactional sex' developed through research with women does not translate easily to men. Many perceive expectations that they fulfil a provider role, with quid pro quo entitlement to sex. Men distinguished these circumstances of sex from having sex with a woman in prostitution. Whilst there may be similarities, when viewed relationally, these are quite distinct practices. Conflating them is sociologically inappropriate. Efforts to work with men to reduce transactional sex should focus on addressing sexual entitlement and promoting gender inequity.

Carework and caring: A path to gender equitable practices among men in South Africa?

BACKGROUND: The purpose of this study was to examine the relationship between men who engage in carework and commitment to gender equity. The context of the study was that gender inequitable masculinities create vulnerability for men and women to HIV and other health concerns. Interventions are being developed to work with masculinity and to 'change men'. Researchers now face a challenge of identifying change in men, especially in domains of their lives beyond relations with women. Engagement in carework is one suggested indicator of more gender equitable practice. METHODS: A qualitative approach was used. 20 men in three South African locations (Durban, Pretoria/Johannesburg, Mthatha) who were identified as engaging in carework were interviewed. The men came from different backgrounds and varied in terms of age, race and socio-economic status. A semi-structured approach was used in the interviews. RESULTS: Men were engaged in different forms of carework and their motivations to be involved differed. Some men did carework out of necessity. Poverty, associated with illness in the family and a lack of resources propelled some men into carework. Other men saw carework as part of a commitment to making a better world. 'Care' interpreted as a functional activity was not enough to either create or signify support for gender equity. Only when care had an emotional resonance did it relate to gender equity commitment. CONCLUSIONS: Engagement in carework precipitated a process of identity and value transformation in some men suggesting that support for carework still deserves to be a goal of interventions to 'change men'. Changing the gender of carework contributes to a more equitable gender division of labour and challenges gender stereotypes. Interventions that promote caring also advance gender equity.

South African teachers' responses to teenage pregnancy and teenage mothers in schools.

South African law forbids excluding pregnant teenagers from school and permits young parents to continue with their schooling. However, the existence of progressive policy and law does not by itself ensure that pregnant teenagers and young parents remain in school or experience as little disruption to their studies as possible. Two of the factors influencing the experiences that pregnant girls and young parents have are the attitudes and practices of teachers. We explore how teachers in diverse South African secondary schools respond to young women's pregnancy and parenting. Teachers' responses are situated within a complex set of meanings invoking sexuality (and sexual censure), gender, class and race. We argue that many teachers view teenage pregnancy and parenting as social problems - a domain of sexual shame with negative effects and disruptive to the academic life of the school (including teachers and other learners). Teachers do not monolithically subscribe to such negativity and, in the context of changing policy and gender equality, there are glimmers of hope. Without much support, training or any formal school-based support, many teachers show care and concern for pregnant women and young parents, providing some hope for better experiences of schooling.

Empowering teenagers to prevent pregnancy: lessons from South Africa.

Reducing rates of teenage pregnancy is an important part of the agenda of action for meeting most of the Millenium Development Goals. South Africa has important lessons for other countries in this regard as the rate of teenage pregnancy is high but has declined very substantially over the last twenty years. The country experiences waves of moral panic about teenage pregnancy, with assertions that current problems are rooted in accepting or even encouraging the sexual appetites of young people rather than sternly disciplining them. In this paper, we argue that the key to success in teenage pregnancy reduction has been an empowering social policy agenda that has sought to work with young people, making them aware of their rights and the risks of sexual intercourse. Furthermore, family responses and education policy have greatly reduced the potential negative impact of teenage pregnancy on the lives of teenage girls. There is tremendous scope for further progress in reducing teenage pregnancy and we argue that this lies in paying more attention to issues of gender and sexuality, including the terms and conditions under which teenagers have sex. There needs to be critical reflection and engagement with men and boys on issues of masculinity, including their role in child rearing, as well as examination within families of their engagement with supporting pregnancy prevention and responses to pregnancies.

Goals and Adverse Effects: Rate of Concordance Between Patients and Providers.

PURPOSE: Adequate understanding of the goals and adverse effects of cancer treatment has important implications for patients' decision making, expectations, and mood. This study sought to identify the degree to which patients and clinicians agreed upon the goals and adverse effects of treatment (ie, concordance). METHODS: Patients completed a demographic questionnaire, the National Comprehensive Cancer Network Distress Thermometer, the Medical Outcomes Study Social Support Survey, the Functional Assessment of Chronic Illness Therapy-Treatment Satisfaction-General questionnaire, the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being questionnaire, and a 13-item questionnaire about the goals and adverse effects of treatment. Providers completed a 12-item questionnaire. RESULTS: One hundred patients (51 female) and 34 providers participated (questionnaire return rate mean difference, 5 days; SD, 16 days). Patient and provider dyads agreed 61% of the time regarding the intent of treatment. In cases of nonagreement, 36% of patients reported more optimistic therapy goals compared to providers. Patients and providers agreed 69% of the time regarding the patient's acknowledgement and understanding of adverse effects. Patients who reported an understanding of likely adverse effects endorsed significantly lower distress scores (mean, 2.5) than those who endorsed not understanding associated adverse effects (mean, 4.1; P = .008). CONCLUSION: Timely data capturing of patient-provider dyadic ratings is feasible. A significant discrepancy exists between a substantial percentage of patients' and providers' views of the intent and adverse effects of treatment. Patients were almost always more optimistic about the intent of treatment. Higher rates of distress were noted in cases of discordance. Providers may benefit from conversational feedback from patients as well as other integrated feedback systems to inform them about patient understanding.

An automated system for detecting nonadherence in laboratory testing and monitoring for myelosuppression in patients receiving self-administered oral chemotherapy.

INTRODUCTION: Patient compliance with routine monitoring for self-administered chemotherapy is problematic. We sought to assess monitoring lapses and incidents of myelosuppression in patients undergoing self-administered chemotherapy for glioblastoma, as well as test software designed to detect and alert clinicians to lapses in monitoring. PATIENTS AND METHODS: A retrospective analysis was conducted to identify patients (N=117) who received standard oral temozolomide for glioblastoma at our institution from 2003 to 2010. Gaps in monitoring were classified as minor (10 to 12 days) or major (13 to 28 days), and adverse events were graded using standard criteria. During the prospective portion of the study, we tested a software-based system that alerted clinicians of monitoring lapses and adverse events among patients receiving self-administered temozolomide for glioblastoma (n=37). RESULTS: Our retrospective review found that 34 of 117 patients experienced monitoring gaps during treatment. No association between gaps and risk of myelosuppression were found. Patients with gaps were more likely to be male (P=.04). Patients monitored prospectively with the software experienced no major gaps in monitoring (P=.007 compared with retrospective patients). CONCLUSION: Our retrospective review demonstrated that monitoring nonadherence was occurring at a substantial rate. Our computerized system eliminated major gaps in monitoring in the prospective portion of our study. Although there is no association between monitoring gaps and the occurrence of adverse events, when they do coincide, continuing oral chemotherapy during an unrecognized adverse event may worsen the patient's condition. Automated systems are justified and serve a function not currently being addressed.

Men, prostitution and the provider role: understanding the intersections of economic exchange, sex, crime and violence in South Africa.

BACKGROUND: South African policy makers are reviewing legislation of prostitution, concerned that criminalisation hampers HIV prevention. They seek to understand the relationship between transactional sex, prostitution, and the nature of the involved men. METHODS: 1645 randomly-selected adult South African men participated in a household study, disclosing whether they had sex with a woman in prostitution or had had a provider relationship (or sex), participation in crime and violence and completing psychological measures. These became outcomes in multivariable regression models, where the former were exposure variables. RESULTS: 51% of men had had a provider relationship and expected sex in return, 3% had had sex with a woman in prostitution, 15% men had done both of these and 31% neither. Provider role men, and those who had just had sex with a woman in prostitution, were socially conservative and quite violent. Yet the men who had done both (75% of those having sex with a woman in prostitution) were significantly more misogynist, highly scoring on dimensions of psychopathy, more sexually and physically violent to women, and extensively engaged in crime. They had often bullied at school, suggesting that this instrumental, self-seeking masculinity was manifest in childhood. The men who had not engaged in sex for economic exchange expressed a much less violent, more law abiding and gender equitable masculinity; challenging assumptions about the inevitability of intersections of age, poverty, crime and misogyny. CONCLUSIONS: Provider role relationships (or sex) are normative for low income men, but not having sex with a woman in prostitution. Men who do the latter operate extensively outside the law and their violence poses a substantial threat to women. Those drafting legislation and policy on the sex industry in South Africa need to distinguish between these two groups to avoid criminalising the normal, and consider measures to protect women.

The relationship between intimate partner violence, rape and HIV amongst South African men: a cross-sectional study.

OBJECTIVE: To investigate the associations between intimate partner violence, rape and HIV among South African men. DESIGN: Cross-sectional study involving a randomly-selected sample of men. METHODS: We tested hypotheses that perpetration of physical intimate partner violence and rape were associated with prevalent HIV infections in a cross-sectional household study of 1229 South African men aged 18-49. Violence perpetration was elicited in response to a questionnaire administered using an Audio-enhanced Personal Digital Assistant and blood samples were tested for HIV. A multivariable logistic regression model was built to identify factors associated with HIV. RESULTS: 18.3% of men had HIV. 29.6% (358/1211) of men disclosed rape perpetration, 5.2% (63/1208) rape in the past year and 30.7% (362/1180) of had been physically violent towards an intimate partner more than once. Overall rape perpetration was not associated with HIV. The model of factors associated with having HIV showed men under 25 years who had been physically violent towards partners were more likely to have HIV than men under 25 who had not (aOR 2.08 95% CI 1.07-4.06, p = 0.03). We failed to detect any association in older men. CONCLUSIONS: Perpetration of physical IPV is associated with HIV sero-prevalence in young men, after adjusting for other risk factors. This contributes to our understanding of why women who experience violence have a higher HIV prevalence. Rape perpetration was not associated, but the HIV prevalence among men who had raped was very high. HIV prevention in young men must seek to change ideals of masculinity in which male partner violence is rooted.

Gender inequitable masculinity and sexual entitlement in rape perpetration South Africa: findings of a cross-sectional study.

OBJECTIVE: To describe the prevalence and patterns of rape perpetration in a randomly selected sample of men from the general adult population, to explore factors associated with rape and to describe how men explained their acts of rape. DESIGN: Cross-sectional household study with a two- stage randomly selected sample of men. METHODS: 1737 South African men aged 18-49 completed a questionnaire administered using an Audio-enhanced Personal Digital Assistant. Multivariable logistic regression models were built to identify factors associated with rape perpetration. RESULTS: In all 27.6% (466/1686) of men had raped a woman, whether an intimate partner, stranger or acquaintance, and whether perpetrated alone or with accomplices, and 4.7% had raped in the last 12 months. First rapes for 75% were perpetrated before age 20, and 53.9% (251) of those raping, did so on multiple occasions. The logistic regression model showed that having raped was associated with greater adversity in childhood, having been raped by a man and higher maternal education. It was associated with less equitable views on gender relations, having had more partners, and many more gender inequitable practices including transactional sex and physical partner violence. Also drug use, gang membership and a higher score on the dimensions of psychopathic personality, namely blame externalisation and Machiavellian egocentricity. Asked about why they did it, the most common motivations stemmed from ideas of sexual entitlement. CONCLUSIONS: Perpetration of rape is so prevalent that population-based measures of prevention are essential to complement criminal justice system responses. Our findings show the importance of measures to build gender equity and change dominant ideas of masculinity and gender relations as part of rape prevention. Reducing men's exposure to trauma in childhood is also critically important.

Gender and sexuality: emerging perspectives from the heterosexual epidemic in South Africa and implications for HIV risk and prevention.

Research shows that gender power inequity in relationships and intimate partner violence places women at enhanced risk of HIV infection. Men who have been violent towards their partners are more likely to have HIV. Men's behaviours show a clustering of violent and risky sexual practices, suggesting important connections. This paper draws on Raewyn Connell's notion of hegemonic masculinity and reflections on emphasized femininities to argue that these sexual, and male violent, practices are rooted in and flow from cultural ideals of gender identities. The latter enables us to understand why men and women behave as they do, and the emotional and material context within which sexual behaviours are enacted.In South Africa, while gender identities show diversity, the dominant ideal of black African manhood emphasizes toughness, strength and expression of prodigious sexual success. It is a masculinity women desire; yet it is sexually risky and a barrier to men engaging with HIV treatment. Hegemonically masculine men are expected to be in control of women, and violence may be used to establish this control. Instead of resisting this, the dominant ideal of femininity embraces compliance and tolerance of violent and hurtful behaviour, including infidelity.The women partners of hegemonically masculine men are at risk of HIV because they lack control of the circumstances of sex during particularly risky encounters. They often present their acquiescence to their partners' behaviour as a trade off made to secure social or material rewards, for this ideal of femininity is upheld, not by violence per se, by a cultural system of sanctions and rewards. Thus, men and women who adopt these gender identities are following ideals with deep roots in social and cultural processes, and thus, they are models of behaviour that may be hard for individuals to critique and in which to exercise choice. Women who are materially and emotionally vulnerable are least able to risk experiencing sanctions or foregoing these rewards and thus are most vulnerable to their men folk.We argue that the goals of HIV prevention and optimizing of care can best be achieved through change in gender identities, rather than through a focus on individual sexual behaviours.

Gender role and relationship norms among young adults in South Africa: measuring the context of masculinity and HIV risk.

In the global literature on HIV/AIDS, much attention has been paid to the role of gender inequalities in facilitating the transmission of HIV. For women, gender inequality may be manifested in sexual coercion, reduced negotiating power and partnering with older men, all practices that heighten risk for HIV. Less attention, however, has been paid to how men's relationship behaviors may place them at risk for HIV. Using six culturally specific psychometric scales developed in South Africa, this study examined men's and women's gender role and relationship norms, attitudes and beliefs in the context of ongoing partnerships. These measures were then examined in relation to four sexual risk behaviors: frequency of condom use (with primary or secondary partners) and number of partners (last 3 months and lifetime). Participants were 101 male and 199 female young adults aged, 18-24, recruited from a secondary school in northern KwaZulu/Natal province. Associations between gender and relationship scale scores and sexual risk outcomes yielded both expected and contradictory findings. For men, more frequent condom use was associated with higher levels of partner attachment (hyper-romanticism) but also with stronger approval of relationship violence and dominant behavior. In contrast, for women, more frequent condom use was correlated with a lower endorsement of relationship violence. Men with lower relationship power scores had fewer sexual partners in the preceding 3 months, while women with more egalitarian sexual scripts reported more sexual partners, as did those with higher hyper-romanticism scores. In logistic regression analysis, more egalitarian relationship norms among men were predictive of less consistent condom use, as were higher relationship power scores for women. These findings are discussed in relation to previous research on gender, heterosexual interactions and masculinity in this area, as well as the implications for HIV prevention programs.

Gender dynamics in the primary sexual relationships of young rural South African women and men.

A substantial body of South African research describes the importance of gender dynamics within sexual relationships as factors underlying HIV risk, yet we know little about these factors among young adults-a group at exceptionally high risk of infection. Our primary objective was to explore the ways that young adult men and women interpret and enact gender roles within their established primary partnerships, and how these dynamics influence sexual behaviour in relation to HIV risk. We employed script theory to frame our analysis of the dynamics of gender. Fifty students (25 women, 25 men) at secondary schools in a rural district of KwaZulu/Natal, South Africa completed in-depth interviews about sexual interactions with their primary partner. While many participants indicated that the standards of sexual conduct within relationships reflect dominant gender role norms, our findings indicate that there are important variations in these roles with some male and female respondents accepting and reinforcing the rights of women to determine the nature of sexual interactions. Efforts aimed at improving acceptance and adoption of alternative scripts for women and men may help to broaden young people's repertoire of HIV prevention options.