Male Sexual Partners of Adolescent Girls and Young Women in Haiti: A Survey of HIV Risk Behavior, HIV Service Use, and Partner Violence

"Across the cascade, perceptions of social norms and partner communication were consistently related to HIV behaviors reported by men. These social influences should be incorporated in interventions to promote condom use, HIV testing, and other HIV-related behaviors."

In Haiti and other countries, the Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe (DREAMS) Initiative is a global effort to accelerate the reduction in new HIV infections among adolescent girls and young women (AGYW). One core intervention for the DREAMS Initiative is to reach male sexual partners of AGYW with effective HIV interventions. However, HIV-related data on these male partners are limited. For this reason, the United States Agency for International Development (USAID) in Haiti commissioned the USAID- and United States President's Emergency Plan for AIDS Relief (PEPFAR)-funded MEASURE Evaluation project to study male sexual partners in areas where DREAMS interventions for girls are being implemented.

A cross-sectional social and behavioural survey was administered to 500 male partners of AGYW in Port-au-Prince (PaP) and 300 men in St. Marc from February-March 2019. Selected communication-centred findings:

• HIV knowledge was higher among those who had attended an HIV educational activity, but only 39% of the respondents in PaP and 44% in St. Marc had participated in an HIV educational activity. Having high HIV knowledge did not increase the chance that men would report condom use, nor did having a high perceived risk of HIV (PRHIV).
• Men often talked about condoms with male friends and also obtained condoms from them. They were more likely to use condoms if they thought their male friends did so. Almost all men felt comfortable talking to their female sexual partners about condoms. Men who had done so were more likely to have used condoms with those partners.
• Men with higher HIV knowledge and who reported high-risk sexual behaviour (being 6 or more years older than their partner and multiple concurrent partnerships, or MCPs), were more likely to have been tested for HIV.
• About one-half of the men had talked to their AGYW about HIV testing, and those who had done so were more likely to have been tested. However, when discussing HIV with their sexual partners, the men typically asked about the partner's HIV status rather than talking about their own.
• After sexual partners, male friends were most able to influence men's decisions about HIV testing. Although few men (about one-third) thought that their male friends had been tested for HIV, those who thought so were more likely to have been tested themselves.
• Disclosure of HIV serostatus was low, with only 11 of the 30 HIV-positive participants having told someone about their status, most often a male friend.
• Most men (about 3 in 4) perpetrated emotional violence toward their AGYW partners, usually by trying to control what they did. Whereas about one-half of the men reported equity in decision making in the context of specific decisions, most men felt that, in general, they had more power in the relationship than their AGYW sexual partners.

In short, the results of this Haitian study "indicate a critical need to increase men's knowledge of HIV treatment, access to condoms, and use of HIV testing services. Efforts to decrease physical and sexual violence and to better understand the role of equity in decision making with sexual partners are also needed."

Sample communication-centred recommendations:

• HIV interventions in Haiti should use peer social norms to promote behaviours among men and should be tailored to their preferences by locating services in community settings and in places where men are more likely to socialise. HIV programmes can use interpersonal social networks to reach high-risk heterosexual men and refer them to programmes. When possible, these initiatives should include a community mobilisation component to reinforce the perception of behaviours as a social norm. Aligning HIV programmes with livelihood strategies is also important because of gender-related pressure for men to fill social roles as providers for themselves and their families.
• Reaching additional high-risk men with HIV testing services could be accomplished in Haiti by increasing community-based strategies and promoting provider-initiated testing. Most men in the current study reported being motivated to get tested for HIV as part of routine healthcare, indicating that incorporating HIV testing in broader health promotion could work in Haiti, too.
• Incorporating gender-based-violence prevention messaging in HIV testing services aimed at men could be an effective way to make inroads for both health outcomes. If current HIV testing programmes expand to include more community-based strategies, it is important that they maintain a high level of quality in counseling and condom distribution.
• There was some disconnect between HIV knowledge and PRHIV among men in this study. One way to combat the "optimism bias" is through educational activities and broader messaging campaigns, including testimonials, that depict heterosexual men as at risk for HIV.
• Informational and educational campaigns may do better to focus on promoting desired behaviours (condom use and HIV testing) as normative, rather than trying to increase them through more HIV education about transmission.
• The availability of treatment for HIV in Haiti is one area where broad informational and educational messaging is needed. Few participants in this study were aware of it, which may deter them from being tested for HIV out of fear that the only outcome would be potential stigma.
• Peer social support groups have been suggested to increase antiretroviral therapy (ART) adherence among men, although the format should be adapted to fit male preferences, perhaps through the use of chat-based online groups rather than in-person gatherings. Men may also respond better to one-on-one support through peer navigation than to a group-based setting.
• Post-test counseling for men should emphasise the importance of HIV-status disclosure to partners and HIV testing for couples. HIV-positive men in this study most often disclosed to a male friend, highlighting the promise of using male peer group approaches in Haiti.
• Interventions that could be considered in Haiti to reduce male perpetration of violence toward AGYW partners include: (i) An adapted, 10-session school-based curriculum, recently pilot-tested in the Artibonite department, was found to increase knowledge about dating violence among adolescent boys and girls; (ii) An intervention conducted in South Africa using a modular curriculum - implemented for couples together - showed improvements in partner communication, conflict resolution, and gender-equitable norms. (iii) The community-level SASA! intervention in Uganda to change gender norms about partner violence was shown to lower acceptance of partner violence, lower experience of physical and sexual violence among women during the previous year, and lower male sexual partner concurrency.

The results of the study were intended to be used by government agencies, donors, programme implementers, and researchers in the field of HIV who contribute to the development of policies and programmes designed to reach male sexual partners of AGYW effectively with HIV services in Haiti and similar epidemiological and cultural contexts.