Social Science & Medicine 89 (2013) 45e52

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Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Dividuality, masculine respectability and reputation: How masculinity

affects mens uptake of HIV treatment in rural eastern Uganda
Godfrey E. Siu a, b, d, *,1, Janet Seeley a, c, e,1, 2, Daniel Wight d, 3
a

MRC/UVRI Uganda Research Unit on AIDS, P.O Box 49, Entebbe, Uganda
Child Health and Development Centre, College of Health Sciences, Makerere University, P.O Box 6717, Kampala, Uganda
c
School of International Development, University of East Anglia, Norwich NR4 7TJ, United Kingdom
d
MRC Social & Public Health Sciences Unit, 4 Lilybank Gardens, Glasgow G12 8RZ, United Kingdom
e
London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E7HT, United Kingdom
b

a r t i c l e i n f o

a b s t r a c t

Article history:
Available online 28 April 2013

There is increasing evidence in SSA that once infected with HIV men are disadvantaged compared to
women in terms of uptake of treatment. In Uganda fewer men are on treatment, they tend to initiate
treatment later, are difcult to retain on treatment and have a higher mortality while on treatment. This
article discusses how mens response to HIV infection relates to their masculinity. We conducted
participant observation and in-depth interviews with 26 men from a rural setting in eastern Uganda, in
2009e2010. They comprised men receiving HIV treatment, who had dropped treatment or did not seek it
despite testing HIV positive, who had not tested but suspected infection, and those with other symptoms
unrelated to HIV. Thematic analysis identied recurrent themes and variations across the data. Men drew
from a range of norms to full the social and individual expectations of being sufciently masculine. The
study argues that there are essentially two forms of masculinity in Mam-Kiror, one based on reputation
and the other on respectability, with some ideals shared by both. Respectability was endorsed by the
wider society, while reputation was endorsed almost entirely by men. Mens treatment seeking behaviours corresponded with different masculine ideologies. Family and societal expectations to be a
family provider and respectable role model encouraged treatment, to regain and maintain health.
However, reputational concern with strength and the capacity for hard physical work, income generation
and sexual achievement discouraged uptake of HIV testing and treatment since it meant acknowledging
weakness and an HIV patient identity. Mens dividuality allowed them to express different masculinities in different social contexts. We conclude that characteristics associated with respectable masculinity tend to encourage mens uptake of HIV treatment while those associated with reputational
masculinity tend to undermine it.
2013 Elsevier Ltd. All rights reserved.

Keywords:
Masculinity
HIV treatment
Dividuality
Respectability
Reputation
Uganda

Introduction
Gender equality in access to HIV treatment in high prevalence
settings, particularly sub-Saharan Africa (SSA), has attracted signicant interest in recent years. Although women in most parts of
SSA, and Uganda in particular, still have a higher prevalence of HIV

* Corresponding author. Child Health and Development Centre, College of

Health Sciences, Makerere University, P.O Box 6717, Kampala, Uganda.
Tel.: 256414541684; fax: 256414531677.
E-mail addresses: giu@chdc.mak.ac.ug (G.E. Siu), J.Seeley@uea.ac.uk (J. Seeley),
d.wight@sphsu.mrc.ac.uk (D. Wight).
1
Tel.: 256417704000; fax: 256414321137.
2
Tel.: 441603593370.
3
Tel.: 441413573949; fax: 441413372389.
0277-9536/$ e see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.socscimed.2013.04.025

than men (Ministry of Health (MoH) Uganda, ICF International,

Calverton Maryland USA, Centers for Disease Control and
Prevention Entebbe Uganda, Uganda, U. S. A. f. I. D. K., & WHO
Kampala Uganda, 2012; UNAIDS, 2010), there is growing evidence
that, once infected, men are more disadvantaged in terms of access
to HIV treatment compared to women (Amuron et al., 2007; Birungi
& Mills, 2010; Braitstein, Boulle, & Nash, 2008; Muula et al., 2007;
Nattrass, 2008). In Uganda, compared to women fewer men are on
HIV treatment, they tend to initiate treatment later, are difcult to
retain on treatment and have higher mortality on treatment
(Alibhai et al., 2010; Kigozi et al., 2009; Lubega et al., 2010; Mermin
et al., 2008; Nakigozi et al., 2011).
Mens under-utilisation of HIV/AIDS treatment in high prevalence settings contrasts starkly with initial fears that they would
disproportionately access treatment compared to women (Pirkle,

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G.E. Siu et al. / Social Science & Medicine 89 (2013) 45e52

Nguyen, Ag Aboubacrine, Ciss, & Zunzunegui, 2011), and also

contrasts with mens greater access to nearly all resources due to
their more powerful patriarchal position in society (Greig, Kimmel,
& Lang, 2000). Mens failure to access treatment means a signicant
care and economic burden to the health system and their families,
as well as increased chances of onward HIV transmission to partners (Mills, Beyrer, Birungi, & Dybul, 2012; Peacock et al., 2008).
This is a critical policy concern, and highlights the urgent need to
identify the underlying factors, in order to modify them to improve
mens use of health services (Hirsch, 2007).
The majority of the above studies from Uganda and elsewhere in
SSA have only described the categorical gender differences in access to treatment, without detailing how norms associated with
masculinity may constrain or facilitate mens HIV treatment
seeking. There are, however, some important exceptions, from
northern and southern Africa e.g., Bila and Egrot (2009), Fitzgerald,
Collumbien, and Hosegood (2010) and Skovdal et al. (2011). These
studies suggest that there is often a contradiction between mens
understandings of masculinity and the biomedical representations
of a good patient, undermining their use of HIV services. In urban
central Uganda, living with HIV threatens the embodiment of notions of masculinity such as the ability to have sex, have children,
earn money and provide for ones family, and the resulting stigma
undermines testing (Wyrod, 2011). But these kinds of analyses are
just emerging in SSA, and there is insufcient understanding of
how the different dimensions of masculinity affect mens HIV
treatment seeking behaviour, especially those that encourage it.
Framing the discussion around Helle-Valles (2004) notion of
contextualised dividuality, and Wilsons (1969) model distinguishing respectability and reputation, this article contributes
to the literature by examining mens construction of masculinity
and its inuence on treatment seeking for HIV in Mam-Kiror village
in Busia district, rural eastern Uganda. Mam-Kiror is a pseudonym.
Theoretical framework and concepts
Gender and masculinity
Gender denotes the social construction of characteristics, behaviours, norms and roles considered appropriate for males or females (Hearn, 2001). Masculinity is the social and cultural
expression of what it means to be a man (Kimmel, 1987). Analysing
masculinity as a power relationship, Connell (1998) argued that in
every society there is usually a culturally dominant ideal of masculinity against which all other (subordinate) masculinities are
measured: hegemonic masculinity. However, other scholars have
challenged the implication of homogeneity and argued that, given
the diversity of experiences upon which notions of masculinity are
constructed, masculinity varies between and within societies, so
there are multiple masculinities (Flood, 2004).

He argued that respectability accrued from and/or was afrmed by

proper attention to the requisites of marriage and providing for
children, consistent hard work, and adequate material possessions
such as a home, economic independence and education, as well as
the ideals of the church. Therefore, respectability was concerned
largely with morality and membership of, and active commitment
to, the whole/external society.
By contrast, reputation was the honour accrued to a man as a
result of his masculine activities. According to Wilson, reputation
was almost entirely shaped by the perception of male peers and
was oriented towards prociency in allemale activities and roles
including sexual prowess, fathering many children, gamesmanship skills, including toughness and authority-defying behaviour,
and being smart, as in skills for seducing women or outwitting
others, and prociency in undermining or circumventing the legal
system. Wilson contends that reputation reects the congruence of
how a man views himself and how he is viewed by other males, and
it relies upon peer groups of approximately equal life situations
which provide the ingredients and platform of interaction. While
both men and women participate in the value system of respectability, reputational values are shaped and endorsed almost
entirely by men.
Dividuality
Helle-Valles (2004) theoretical insights into peoples multiple
sexual identities in Botswana can help us understand how men
could simultaneously conform to the values of respectability and
reputation. The dividuality thesis was rst proposed by anthropologist Marilyn Strathern to explain Melanesian social and gender
relations. She argued that unlike the western notion of individual,
the Melanesian person is multiply authored and is complexly
positioned within a network of relations, and therefore is dividual
(Strathern, 1988). Likewise, Helle-Valle argued that local social
norms in Botswana required people to present themselves and act
as appropriate to their immediate social context, even if this contradicts how they presented themselves in a different context.
While some cultures attach importance to individuality, which
assumes that a person thinks and acts according to an essential
identity, Helle-Valle argued that in Botswana every subject is in
very basic ways a different person (dividual) depending on the
context and social relations of which they are part (Helle-Valle,
2004). Thus the dividual concept of a person perceives him/her to
comprise a complex of separable but essentially inter-dependent
and interrelated dimensions of social life. That is, every person
belongs to multiple interrelated social contexts, in and out of which
they move routinely. Helle-Valle argued that being dividual means
acknowledging and relating the various communicative contexts in
appropriate ways, and trying to balance dividuality with being individual; that is conning ones personality to its appropriate
contexts.

Masculine respectability and reputation

Methods
In this article we draw on Wilsons (1969) concepts of
respectability and reputation. In a review of ethnographic studies
of the social structure of Caribbean societies, Wilson (1969) suggested that these concepts informed two closely interconnected
value systems by which men related their position in society. These
value systems structured mens social relationships, shaped how
their identities were produced, maintained, and challenged, and
governed their conduct within the community. Respectability was
the degree of conformity to the ideals of the whole legal society,
based largely on Eurocentric middle-class values. By legal society
Wilson implied the moral values of institutions such as the family
and church, in which one could participate in an ofcial capacity.

This study draws on ethnographic data collected from an artisanal gold mining community between August 2009 and August
2010. Mam-Kiror village is located in Busia District, 196 km south
east of Kampala, Uganda, with a population of about 750 people,
the majority of whom were Iteso. It had a higher HIV prevalence
(10%) compared to the national prevalence of 7.3%.
The second and third authors were not involved in conducting
the eldwork, but the rst carried out in-depth interviews with 26
men: nine receiving free HIV treatment from a public facility; eight
who had dropped out or had not initiated treatment despite
testing; six who suspected HIV infection but had not sought

G.E. Siu et al. / Social Science & Medicine 89 (2013) 45e52

testing; and three who had other health concerns unrelated to HIV,
to provide some comparison with the men living with HIV. Interviews were based on a exible topic guide, were audio recorded
and transcribed. The interviewees were aged between 27 and 51
years, and all except four were married and had children. Although
only 10 men reported being currently involved in artisanal gold
mining, all had been at some stage in their lives. Three had recently
closed their businesses due to illness or other challenges, most had
multiple sources of livelihood and they generally earned small
incomes.
Interviews were complemented with participant observation.
The rst author lived in the study village for a year, interacting with
the residents, including the interviewees, and conducting conversations related to social life, masculinity and health. First, the
eldwork involved incidental observations and conversations to
establish relations and gain acceptance, but as the study progressed, it focused more on collecting vital information about the
village relating to the local economy and different social groups of
men and their daily life concerns, especially those relating to health
and masculinity. Participant observation was primarily with men,
and predominantly in eating places and bars, interviewees homes
and workplaces and village social events. Although beer drinking
and work in the mines were frequently observed the researcher did
not participate in them, which limited the data collected. Less data
were collected from women, young people or children, although for
some consenting men, data were collected from their wives, other
relatives or friends.
The rst author translated most of the interviews and identied
preliminary thematic categories from the transcripts and observation notes to create a coding schedule. Explicit themes were prioritised for coding, but the analysis process was open to
unexpected categories. All three authors then discussed the identied thematic areas and agreed on a nal coding frame, following
which systematic coding was undertaken using NVivo 8. Coded
data were summarised systematically in a matrix table to display
and generate concepts, establish patterns, variations and recurrent
themes across the codes, and to check emerging hypotheses against
all relevant data (Ritchie & Lewis, 2003).
The study was approved by the science and ethics committees of
Uganda Virus Research Institute, Faculty of Social Science, University of Glasgow and the Uganda National Council of Science and
Technology. Consent for the interviews was obtained from
participants.
Findings
Distinguishing two forms of masculinities in Mam-Kiror
Men in Mam-Kiror drew from a range of norms and attributes to
full the social and individual expectations of being sufciently
masculine. Despite a shared general understanding of masculinity,
variations in individual mens accounts suggested that there are
essentially two forms of masculinity in Mam-Kiror, one based on
reputation and the other on respectability(Wilson, 1969); each
consisting of various masculine ideals. However, these two overlap
in that they were endorsed by men amongst themselves and by the
wider society. The respectable values endorsed by the wider society, primarily women but also including some men, in-laws,
religious ministers, etc., which contributed to respectability,
included marriage, fathering and providing for children, sexual delity, demonstration of wisdom and respect of self and others. For
example, when asked what made one sufciently masculine, Paul, a
28 year old man, said: Marriage and children; for a mature man, it
is these. Providing for the family was an especially important
measure of conformity to the value system of responsibility

47

and respectability because it demonstrated hard work and

independence.
The reputational ideals endorsed predominantly by men
amongst themselves included sexual achievement and fathering
many children, physical strength, a work ethic, socialising and
compulsory spending on leisure. Mens views on how masculine
identity was established through various reputational ideals
sharply contrasted with the views of the wider society. For instance,
most men, particularly the younger men, valued multiple sexual
relationships, as has been found in many other SSA settings (Barker
& Ricardo, 2005; Jonason & Fisher, 2008; Nyanzi, Nyanzi-Wakholi,
& Kalina, 2008; Plummer & Wight, 2011; Ragnarsson, Townsend,
Ekstrm, Chopra, & Thorson, 2010). However, wives and relatives
had counter-arguments, maintaining that respectability was lost,
especially for older men, by failing to exercise self-control and
minimise the number of sexual partners, and by spending family
resources on them. Yet, the contribution of sexuality to masculine
identity in Mam-Kiror was complex and context dependent. For
example, as found in Botswana (Helle-Valle 2004), sexually promiscuous men did not have a singular thought on delity. One man
was capable of presenting himself as a loving and caring husband to
his wife, but when interacting with peers and rival partners, presented himself as a strong and powerful rival sexual partner. In
Uganda, secrecy and discretion about extramarital relationships
allows men to manage their public reputations and maintain the
appearance of being moral and faithful (Parikh, 2007). These forms
of identity presentations by the men of Mam-Kiror suggest that
theoretically it is possible for there to be both congruence and
contradiction in the way a man views himself and the way he is
viewed by others within the value systems of both reputation and
respectability.
The distinction between respectable and reputational masculinities was at times, more complex, however. For instance men,
even the younger ones, sometimes wanted to establish their
respectability with other men, such as their afnes. The presence of
different forms of masculinity in Mam-Kiror suggests that there is
no single male gender identity (Kimmel, 2001) and a masculine
attribute considered appropriate in one specic situation, may, in
another social context or phase of life, be conveniently substituted
by an alternative. Mens dividuality explains their ability to adopt
different and sometimes contradictory forms of masculinity in
different social circumstances and phases of life.
Age, family structure, economic status and type of employment,
appeared to be the primary factors that shaped the kind of masculinity that one endorsed. For instance, men engaged in artisanal
gold mining, the dominant source of cash for men in Mam-Kiror,
constructed their identity differently from non-miners. While
they were not homogenous, the gold miners tended to portray
themselves as distinct in having embraced the challenges and risks
of mining. Many proudly recounted their experience and skills in
mining which put them above non-miners and also above other
miners. They were also under pressure to conform to miners
renowned characteristics. For instance, their masculine identity as
brave men or hard workers was especially central to their coping
with the threats of injury and exhaustion from the highly strenuous
mining work, as found among miners in South Africa (Campbell,
1997). However, while miners reputation as regular earners and
big spenders encouraged them to conform to a compulsory
expenditure pattern, primarily on leisure, and earned glorifying
nicknames before peers and sexual partners, it contradicted their
attempts to ensure their familys economic progress, in turn
undermining their respectability as perceived by their family and
wider society. In contrast education appeared insignicant in
shaping masculinity in this setting. Given that most men had
minimal education, it was not the primary means to accessing

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G.E. Siu et al. / Social Science & Medicine 89 (2013) 45e52

employment or a higher social status, although teachers, the most

common professionals in Mam-Kiror village, were valued for their
role. Similarly, although religious conversion was seen as a search
for a new identity, and most people in Mam-Kiror acknowledged
that the evolving religious identities made possible new ways of
behaving, religious consciousness largely, appeared peripheral to
most men. Men, who converted to new religious faiths, especially
to Pentecostalism, were often regarded with mixed feelings: they
were seen as seeking cheap means to enrich themselves through
free collections rather than hard work.
Generally, mens accounts of masculinity in Mam-Kiror
demonstrated that their sense of identity was not constant, and
that there were tensions, ambiguities and dilemmas in how
different life-course circumstances, contexts and social situations
or groupings demanded modications of gendered presentations.
How masculinity undermines HIV testing and treatment uptake
Couple testing a threat to masculinity
There were many negative perceptions about the different options for testing, with most men being particularly critical of couple
testing. This threatened masculinity and discouraged testing in two
ways. First, the requirement that a couple attend counselling and
testing together to learn their HIV status would potentially lead to
the disclosure of the mans extramarital relationships, which most
had engaged in, thus destabilising marriages. Second, the process of
couple testing and counselling was equated to a man being on trial.
Several men, both during the interviews and informal conversations, stated that some wives, feeling protected by the presence of
the health worker, blamed the man for risking their lives with HIV.
In a conversation with four men one remarked:
It is as if you are before a court, and as you know women can get
authority over the man when other people are there; she knows
you cannot prevent her from talking. So your wife may ask you
how the disease came about. So you have to reveal the extra
affairs that you have got because the doctor asks you about your
partners, telling you to come with them all for testing [Man,
age 40].
Although some studies have observed that fear of blame and
physical abuse discourages couple testing (Allen et al., 2007), many
others have argued that it may simplify disclosure, particularly
because the health worker takes responsibility to reveal the bad
news (Matovu et al., 2005; Matovu & Makumbi, 2007). However,
we argue that in the context of widespread extramarital affairs by
men, couple testing brings mens incompatible dividualities
together: they can no longer keep separate their identities as
faithful husbands, wishing to maintain stable families and endorse
respectable masculinity, and their identities as womanisers,
endorsing reputational masculinity. The failure to keep these
separate identities through couple testing undermined mens
treatment.
Male independence and fear of losing masculine respectability
Endorsing male independence, resilience and being dismissive
of problems made men reluctant to acknowledge the seriousness of
HIV symptoms and assume a sick identity until the symptoms were
acute and life threatening. For some men, not starting or delaying to
start ART was an achievement and an important part of their
masculine identity, which attested to their physical and emotional
strength despite symptoms. Solomon (age 42, suspecting HIV
infection) was a good example of this. When justifying why he had
delayed testing despite recurrent symptoms suggestive of HIV, he
proudly expressed a sense of emotional strength and perception
that he was still in control of his health, saying: I was still strong,

the body was still ghting the thing [illness] on its own. In
contrast, when he became progressively weaker during the eldwork, Solomon began to acknowledge failure to maintain his independence and was ready to test and assume a sick identity,
stating: [.] where it has reached, I think I need to go for an AIDS
test. But our data suggest that men under about 40 may have
found it particularly difcult to admit to physical weakness and
accept illness, perhaps because they were more oriented to
expressing their masculinity through physical strength rather than
respectable masculinity.
The phrase ikiliok edakanaro adekis kikarak konyecut (men are
usually just carried to hospital when they have been overwhelmed) used by some men to describe mens health seeking
behaviour suggests a major challenge regarding treatment seeking
decision making among men. Some men admitted that despite
being adults and married, they were not entirely independent since
they often required the care of their female relatives, alongside or in
the absence of their wives. In West Africa womens HIV care giving
role often extends to queuing for their husbands during medical
consultation because men tend to feel greater shame (Bila & Egrot,
2009), and being unmarried is a risk factor for late initiation into
HIV treatment (Pirkle et al., 2011). But our ndings further point to
a different kind of dependency, whereby men seemed to nd it
difcult to determine, on their own, when to seek treatment, which
contradicts their assumed masculine autonomy and superiority:
these men tended to over rely on others, especially relatives and
wives, for their health care decisions. This means they might not
access services in time, unless other people prevail over them, and
it may explain mens delays in seeking HIV treatment frequently
reported in the ART literature.
The older men found it harder to seek a test compared to the
younger men for fear to lose respectability and dignity if diagnosed
with HIV. Isaiah (age 49) who took long to test despite suspected
HIV infection and severe illness discussed his fears specically with
regard to a mans age and status, emphasising that older men, like
him, were judged more harshly and lost respect because society
expects them to be sexually conservative:
You see, in this place of ours, everybody will be saying now look,
the man you thought was good, sickness has already affected.
So they will say that even old men do not respect themselves! It
is bad, especially for us with big children. And then the issue of
in-laws.I was terried emame bobo ayongit ijo [no more
respect for you]. So you fear to test.
The phrase emame bobo ayongit ijo, used by some men to
describe how others might view them should they be diagnosed
with HIV, implied it would be seen as a failure. Since the wider
society expected mature men to be wise, responsible and sexually
self-controlled, acquiring HIV would undermine others respect and
approval. Skovdal et al. (2011) study of masculinity as a barrier to
mens use of HIV services in Zimbabwe had similar ndings: while
multiple sexual partners were a valued sign of virility, it was equally
important for ones masculinity to have a safer sexuality and so
testing positive was seen as a sign of weakness and failure,
undermining disclosure and the use of HIV services. Furthermore,
our study suggests that older mens infection greatly undermined
their respectability compared to younger men because they were
expected to be sexually unadventurous. Yet, as will be discussed,
once tested and disclosed the older men appeared less concerned
about the negative impact of a positive HIV status on their reputational identity compared to younger men. Since reputational attributes, such as sexuality, were no longer viable for their
masculinity, older men appeared more inclined to regain their
respect by prolonging life through ART and ensuring they cared for
their families.

G.E. Siu et al. / Social Science & Medicine 89 (2013) 45e52

Occupational identity and fear of being marginalised at work

Mens accounts overwhelmingly suggested that the masculine
attributes of the work ethic and money making discouraged mens
uptake of HIV treatment. Disclosing treatment to fellow workers or
employers risked being judged as unable to do strenuous work or as
incompetent, leading to less job offers and collaborative work.
Others were reluctant to work with people known to be sick and/or
on medication. This greatly undermined their reputation as hard
workers and ability to provide for their families.
Artisanal gold miners were particularly concerned about being
side-lined because in collaborative tasks showing weakness was
detrimental to the group, while physical weakness due to HIV
related illness or the persistent side-effects of ART destabilised
work and threatened their hard won occupational identity as hard
working miners. As longevity and personal success in this industry
brought pride, quitting mining was difcult. Among the many examples, Jumas (age 51, dropped ART) was most revealing:
It [mining] is the work that we men of this place know. For
example, I started digging gold many years ago. I dug it for almost
20 years and left but now again I am back to it. For such men, if
they could not disguise their treatment they abandoned it. This
suggests that work in the context of ART among men in Mam-Kiror
was not only an economic necessity but also a crucial aspect of
redening personhood following ART, especially amongst men who
greatly relied on their strength for physical labour, as Alcano (2009)
found in Italy. In our study having work, and capacity to do hard
physical work, was valued beyond the income, and being a gold
miner had a higher status than other local occupations, making
quitting difcult, as also found in the Congo (Perks, 2011).
Waiting times in clinics were also a hindrance. First, waiting
with women contradicted the local gender norm that men are
served before women. Second, it had an impact on mens work:
When you go to the hospital, you must be prepared to spend a
long time there; sometimes the entire day if you are not careful,
which is a problem because you might be missing your work.
This is bad for us here because when you work (mine gold) in a
group your friends will note each time you are away and give
you less share of the ore [Man, aged 42].
Although the observation in clinics could not reveal whether
clinic attendance itself marked them as HIV positive men, such as
Leo, expressed anxiety lining up with other people: [.] the problem that I nd when collecting the drugs is when you are told to
come to the clinic when everybody is supposed to come..you line
for long hours.
Fear of repercussions of defaulting
Men who had stopped taking their drugs but realised the need
to return were worried about being criticised and extremely
doubtful of their chances of being re-admitted, as Isaiah explained:
[.] you know even now, in case I got the opportunity to go back
[for treatment], I am sure it will be a serious case, it will involve
ewosan loepol noi (very serious interrogation). In fact, I think
they will send me away because it is a big case: where have you
been is what they will ask. They will reject any reason and you
remain ashamed. It involves being shouted upon like a child,
dont you see, no respect at all!
In South Africa, unsupportive reactions and breaching of trust by
health workers were found to discourage men from attending
health services, since they tended to have high expectations of
health workers professional behaviour (Fitzgerald et al., 2010). This
was also found in Mam-Kiror and it highlights that the discipline
expected when accessing HIV services and sanctions by health

49

workers contradict the conventional autonomy of, and respect for,

men in this society.
How masculinity may encourage HIV testing and treatment seeking:
what works for men?
Not all the norms of masculinity work to mens disadvantage
with regard to uptake of HIV treatment: there are some cultural
gender ideologies and social and personal resources that encouraged some men to test and seek treatment for HIV.
Raising a family and reclaiming social worth
Some men drew on the social construct of male caring roles to
seek HIV treatment. They argued that treatment extends life,
enabling a man to full his roles as a father and husband. Emphasising the centrality of HIV treatment in rebuilding their physical
and social lives and familial roles some men said they had been
resurrected (akikwarun) by treatment. Children were the most
important motivation to stay alive, in particular to father children
and support their education and health, provide land, and be the
father-gure. As Isaac (age 37) described: These medicines are the
ones giving me life-support; it is like being on life..the way they
put someone on life [support system if organs are failing] in hospital, so that I can at least do something for the family. In contrast,
Job (age 45), who had no children and who had separated from his
wife during the eldwork, did not initiate ART despite having
tested positive. When asked about his reluctance to seek treatment,
he linked it partly to his family circumstances, in particular
discussing his lack of children and wife and having nothing to
live for:
At least if you have children, you can say let me also try to keep
these children but now where can you get the energy [incentive]. You are not worried about anything; just saying even if I
go since life is hard.
The desire to regain social worth by contributing positively to
family and society following HIV-related illness and ART is not
intrinsic to men (see e.g., Seeley & Russell, 2010; Timmons & Fesko,
2004). However, it can be argued that restoration of physical health
and ability to work hard due to ART was particularly crucial to these
men since their masculinity was assessed chiey in terms of their
ability to contribute resources for the familys economic progress.
Livelihood support from treatment provider
Receiving support for livelihoods from treatment providers
appeared to motivate men to adhere to their treatment. First, it
helped address a major concern about ability to provide for their
families and restored masculinity, which had been affected by HIV
illness. Second, it provided alternative solitary employment that
allowed exible working and little worry about disclosure to colleagues, in contrast to work with other men.
Three AIDS agencies operated in the area by the time of the
eldwork, but their scale of livelihood support to clients and access
criteria varied signicantly. The AIDS Support Organisation (TASO)
which had its ofces in Tororo, about 24 km away, extended its
medical service to the study village through outreach to Busia
District, normally stationed in the town, from where Mam-Kiror
residents would access testing, counselling, and treatment. In
addition to ART, it supported some groups of patients in the village
with income generation projects on piggery, goats and school fees
grants, although to access it, one had to make an extra effort to seek
it by conding to his treatment provider. The Centres for Diseases
Control (CDC), an ART research programme, also had its ofces in
Tororo, and supported some of clients on individual basis, with
food/nutritional support, clean water and home visits, but it was

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G.E. Siu et al. / Social Science & Medicine 89 (2013) 45e52

winding up by the time of the study. Busia Health Centre IV was a

Ministry of Health facility but apart from treating patients, it did
not provide any material support to its clients.
The men who had received livelihood support and earned cash,
such as Noah (age 50), Salim (age 45), and Abraham (age 50),
expressed a greater sense of commitment to their treatment than
others. They described adherence as a legitimate moral obligation
for them since they were fortunate beneciaries. In contrast, men
such as Isaiah (age 49) who dropped ART, complained that the
government had forgotten some of them, and partly attributed
their decision to drop treatment to lack of livelihood support.
HIV treatment of a spouse and family arrangements
This study found that wives who were themselves receiving HIV
treatment often played a vital role in encouraging their men to
initiate and/or adhere to treatment. Men described them as more
understanding and supportive of their own treatment efforts, since
they shared similar experiences compared to those not on treatment. Noah (age 50, on ART), for example, stated that he was less
anxious now than before [his wife enrolled on ART] because he
was not the only one in his family taking the ART medicine. Such
women provided treatment advice to husbands based on their own
experiences and sometimes helped to pick-up medicines for them.
Leos (age 27) example was perhaps more illustrative. Not only did
he test after his wife, and got an invitation to enrol for treatment
through the antenatal care programme attended by his wife, but he
also acknowledged the help of his wife in regularly picking-up his
drugs for him, without which his continued access to treatment
would have been in doubt. He stated:
I collect the drugs myself, but sometimes I send her when I am
busy. You know I go early in the morning to do my work and
often I take long to come back. We can delay waiting for maize
[to be supplied] so the wife brings for me my drugs.
Some men who had dropped treatment but expressed desire to
return for treatment in future also linked their hopes to their wives
possible future treatment, saying they would resume it when their
wives also started taking the drugs, despite some wives being
conrmed HIV negative. For example, in response to the question
about his future treatment plans, Juma (age 51) said: We shall go
back together [for treatment] with my wife. Jose (age 28), who had
never disclosed to his wife any of his HIV information, also stated:
I will start again when she [wife] also starts. Therefore, we see
that treatment discordance may in some ways be problematic to
mens treatment efforts, while their wifes treatment was an
incentive for men to maintain their own treatment. Other studies
show that couples who have disclosed to each other and received
counselling from the same health facility are likely to adhere better
to HIV treatment (Kiguba et al., 2007). In Zimbabwe, wives
persuasion of their husbands has been found to be an important
factor in mens acceptance to use HIV services (Skovdal et al., 2011).
Advise/pressure from work colleagues
Many accounts and experiences of getting tested for HIV, or
intentions to seek testing, highlighted the role of friends/workmates, although there were some counter-examples such as
Abraham (age 50) who got tested through personal determination
rather than involvement of other parties. Several men who said
their friends had recommended they get tested, or had actually
accompanied them, reported that their colleagues could recognise
their symptoms since they spent a lot of time together and frankly
discussed the risk of HIV and benets of treatment with them.
Some men who had not yet tested but suspected infection also
described coming under pressure or receiving advice from
work friends to undertake a test. Tony (age 39), for example, said:

[.] they [friends] are always telling me to rst test, because they
see that I have no energy, and that I no longer go to dig with them as
a group as before.
Although there was concern about disclosure, some men
thought it was less stigmatising to test together with a colleague,
especially if you are good friends with a similar sexual history: It is
a good idea to plan to go with a friend to test. You get the courage
also because you know that may be you have had similar [sexual]
adventures [Man, age 25]. This was also found in a study of small
scale enterprises in Kabale district, western Uganda, where coworkers tend to advise each other on HIV testing (Twinomugisha,
Danie, & Lie, 2011). In Mam-Kiror, since discussions of health and
sexual matters within work teams were quite common, and
seemed a vital aspect of health seeking for sexual health problems,
such discussions might be encouraged through health promotion.
This might generate new understandings of masculinity that are
more conducive to health management (Nattrass, 2008).
Discussion: why do some men initiate and maintain HIV
treatment and others do not?
The ndings of this research suggest that the specic meanings
that men attach to health seeking for HIV depend on their social
context, pressure and personal circumstances of their lives and the
form of masculinity they endorse. In this article we argue that the
broad dimensions of masculinity e reputation and respectability e
found in Mam-Kiror emerge in different social contexts and phases
of mens lives, and have different effects on mens HIV testing and
treatment seeking behaviour. Three main possible explanations for
variance in the pattern of HIV treatment seeking among men can be
suggested.
First, possessing a strong sense of occupational identity and
working group norms, and regarding physical strength as a core
measure of masculinity, discouraged some men from seeking
testing or maintaining treatment. If treatment was thought to have
failed to restore strength to the previous level, or caused sideeffects that were disruptive to work or that made it difcult to
conceal the diagnosis, it was readily dropped, because treatment
prevented the demonstration of ones previous work ethic and
preservation of the collective work identity (Siu, Wight, & Seeley,
2012). For instance, the miners differed from farmers or others in
non-mining sectors in their perception of the impact of HIV diagnosis on their masculinity, tending to report greater challenges.
This is because, unlike non-mining occupations, mining work was
often structured in work teams and so the concern to demonstrate
hard work, bravery and endurance (Campbell, 1997), and physical
strength and presence at work, most of which were attributes of
reputation, undermined disclosure of HIV and treatment seeking.
Second, in facilitating a shift from mining to alternative selfemployed occupations, the income support received by some
men from treatment providers meant that treatment programmes
came to enhance rather than threaten their masculine work ethic,
ability to provide for family and sense of self-worth. HIV status and
treatment could be more readily concealed and, if disclosed, there
was no danger of being marginalised by other workers. The economic support or livelihood projects from treatment providers or
aid agencies were, thus, useful both in restoring masculinity and in
motivating adherence to HIV treatment, since they not only allow
men to full their key roles as providers and, therefore, being
respectable, but also enabled those who worked in collaborative
employment to shift into exible self-employment, which could be
undertaken without having to worry about disclosure of HIV
treatment to colleagues. Previous studies have also described the
connection between a mans ability to earn money and his reluctance to test. A common theme is that having HIV threatens the

G.E. Siu et al. / Social Science & Medicine 89 (2013) 45e52

embodied notion of a proper provider as job offers and income

declined (Sakhumzi, 2008; Wyrod, 2011).
Third, age and social maturity, measured by marriage, and
economic security (Wilson, 1969), and having grown-up children
and other social responsibilities, appeared to be crucial factors in
mens interpretation of the meaning of masculinity and the value of
HIV treatment. Younger men may have found it particularly difcult to seek help compared to older men because they conformed
more to the values of reputational masculinity than respectability,
such as demonstrating physical strength and independence, which
were inconsistent with the sick patient identity. In contrast, older
men found many reputational values unrealistic, since at their age
their failures and accomplishments as men were evaluated less in
terms of reputation and more in terms of whether they had raised a
respectable family and conformed to other values of the wider
society. Although the older men worried about loss of respectability
by testing HIV positive, once diagnosed they tended to emphasise
the importance of living longer on ART so that it would allow them
to stabilise families and full other social obligations. They saw
protecting their health as a step towards reclaiming social-worth
and respectability, and therefore, easily maintained HIV treatment. In South Africa it has been observed that older men, established in their social roles, were more secure and better able to
disclose and negotiate family support, which was vital for their use
of HIV services, than the younger men who tended to express
greater feelings of failure with regard to building and supporting
families (Fitzgerald et al., 2010). The present study argues that
concerns about reputation, which were common among the
younger men, tended to have far more negative impacts on HIV
treatment than concerns about respectability.
Therefore, it can be argued that the individual mans decision
whether or not to seek treatment for HIV reected his subjective
perception of the social pressures from, and appraisals by, his core
reference groups (family, peers, wider society) but it was also
inuenced by his changing life course experiences and circumstances. Where the reference group subscribed to the values of
respectability, such as performing family responsibilities, men were
likely to seek treatment, in order to extend their performance of
vital social roles and conform to the wider social ideals of masculinity. However, where the reference group subscribed to reputational values, such as sexual achievement, men were less likely to
have favourable attitudes towards admitting HIV infection and/or
seeking treatment.
Mens dividuality is central to their ability to reconcile the
conicting concerns associated with conforming to different
masculine identities, and whether to seek treatment. For instance,
while couple counselling threatened testing and treatment initiation because it threatened a mans authority and exposed his
extramarital relationships, the same men discussed the risk of HIV
when in the company of fellow men, and were willing to be
accompanied by their peers for an HIV test. Because of their
dividuality some men, particularly the older ones and those married with children, were able to justify their treatment seeking by
drawing on their unique social circumstances, in the process
creating an alternative but still a viable masculine identity of
respectability and rejecting reputational identities which did not
favour their treatment.
Conclusion and implications for public health
This is the rst study in Uganda to explore how masculinity
affects mens uptake of HIV treatment by comparing men who are
currently receiving treatment, those who have dropped it, those
who refused to initiate it despite testing positive and those who
have not tested but believe they are infected. The study shows that

51

irrespective of HIV, men of Mam-Kiror drew from a range of ideals

to full the social and individual expectations of being sufciently
masculine. These masculine ideals can be categorised into two
main forms of masculinity e respectable and reputational e with
some ideals being shared by both. Respectable masculinities are
endorsed largely by the wider society, while reputational masculinities are endorsed predominantly by the men themselves.
Theoretically, this categorisation is consistent with the distinction
between the value systems of respectability and reputation as
described by Wilson (1969). Mens ability to adopt, unproblematically, the reputational form of masculinity in one circumstance and
the respectable form in another, could be explained using the
concept of dividuality, as discussed by Helle-Valle (2004).
We found that individual men can engage in a variety of treatment seeking behaviours that typically correspond with different
masculine ideologies and dividualities; some discouraging HIV
treatment, others encouraging it. On the one hand, HIV treatment
may be undertaken and adhered to in order to regain and maintain
health, so as to full family and social expectations, notably being a
provider and role model. On the other hand, the expression of
masculinity through hard physical work, income generation and
sexual achievement may compromise mens uptake of HIV testing
and treatment since the demands and restrictions associated with
ART tend to conict with these norms of reputational masculinity.
These ndings have some implications for public health interventions. Programmes that seek to encourage testing and
treatment need to be more attentive to the values associated with
reputational and respectable masculinities and how each affects
uptake of HIV treatment. For example, ART could be promoted by
emphasising its value in rebuilding a mans respectability and role
as head of family. Men could also be encouraged to go to test with
colleagues, and they need to be supported with livelihood projects
since it can help them provide for their families and encourage
them to maintain HIV treatment. Our ndings raise important
doubts about the suitability of couple testing.
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