Gender and HIV / AIDS : Exploring Men and Vulnerability Towards Effective HIV / AIDS Policy Interventions in Sub-Saharan Africa

his article examines the dynamics between HIV/Aids gender policy strategies and the socio-political demands on HIV/Aids interventions in sub-Saharan Africa. Gender in HIV/Aids intervention seems inescapable. Nowhere else is this more marked than in the social dimensions of HIV/Aids prevention in subSaharan Africa. This has resulted in prevention strategies, which are encumbered by the reality of poverty, gender, access, power and the various debates on behavioural change. The social constructions of gender roles and power relations play a significant role in the region’s HIV /Aids dynamic. To this end, the mainstreaming of gender issues into national political, social and economic agenda and policies has been championed by international development and economic institutions. In developing HIV/Aids intervention policies, gender has also been mainstreamed, especially where epidemiological data show the disparity in infection rates between men and women, where women are seen as more susceptible to infection. The gendered approach to HIV/Aids appears to typecast women as the vulnerable and suffering face of HIV/Aids, while men, as ‘the other’, are generally regarded as the perpetuators and spreaders of the virus. While there is no doubt that women’s vulnerability in this milieu has been proven within known research evidence to exist, the neglect of institutional (social, cultural and economic) and historical vulnerabilities of African men’s realities are sometimes overlooked. Recently, greater focus has shifted to curbing infection rates in men based on new scientific evidence that shows that risk of transmission in circumcised men is reduced. The article argues that such movement towards showing areas of men’s vulnerability as a focus in HIV/Aids policy interventions may have the potential to shift the observed burden that current HIV/Aids policy thrusts inadvertently place on African women. The article will put forward an argument for ‘the vulnerable other’ in HIV/Aids policy intervention, suggesting a new continental policy strategy that sees men going from peripheral footnotes to the centre of HIV/Aids policy and intervention programmes.

The social constructions of gender roles and power relations play a significant role in the region's HIV /Aids dynamic.To this end, the mainstreaming of gender issues into national political, social and economic agenda and policies has been championed by international development and economic institutions.In developing HIV/Aids intervention policies, gender has also been mainstreamed, especially where epidemiological data show the disparity in infection rates between men and women, where women are seen as more susceptible to infection.The gendered approach to HIV/Aids appears to typecast women as the vulnerable and suffering face of HIV/Aids, while men, as 'the other', are generally regarded as the perpetuators and spreaders of the virus.While there is no doubt that women's vulnerability in this milieu has been proven within known research evidence to exist, the neglect of institutional (social, cultural and economic) and historical vulnerabilities of African men's realities are sometimes overlooked.Recently, greater focus has shifted to curbing infection rates in men based on new scientific evidence that shows that risk of transmission in circumcised men is reduced.
The article argues that such movement towards showing areas of men's vulnerability as a focus in HIV/Aids policy interventions may have the potential to shift the observed burden that current HIV/Aids policy thrusts inadvertently place on African women.The article will put forward an argument for 'the vulnerable other' in HIV/Aids policy intervention, suggesting a new continental policy strategy that sees men going from peripheral footnotes to the centre of HIV/Aids policy and intervention programmes.
HIV/Aids in sub-Saharan Africa.To understand the evolution of thought on this issue, this section examines the growth in calls for men-focused interventions in HIV/Aids policy from the turn of the century to date.
A gendered response explores differences between men and women within a particular human endeavour, be it in the social, political or cultural fields.It makes assumptions based on these differences; using these assumptions to best position the issues of development within the various gender structures.Shirin (2002) argues that the gendered arena examines the position of women and men in the ladder of social, political and cultural interaction, their access to resources, and how they mobilise within their various spaces.The United Nations Economic and Social Council (UN ECOSOC) considers gender mainstreaming to be a strategic tool in achieving gender equality.ECOSOC defines 'gender mainstreaming' as "the process of assessing the implication for women and men of a planned action, including legislation, policies or programmes in any area and at all levels" (UNESCO, 2003:18).Consequently, "a gender-based response to HIV/Aids and STDs focuses on how different social expectations, roles, status and the economic power of men and women affect and are affected by the epidemic" (KIT & SAfAIDS, 1998:3).
While the characterisations of gender-based responses and approaches to HIV/Aids interventions seem to embrace the notion of equality between male and female experiences, in practice women have appeared to have a higher priority than men, and are therefore the central recipients of the gender-based approaches to the mainstreaming of HIV/Aids (Rayah & Maposhere, 2003).This woman-focused approach has produced scholarship over the years which argues that there has been a bias in the greater attention placed on the experiences of women in respect of HIV/Aids (Kisoon, Caesar & Jithoo, 2002), even though men are and continue to be, responsible for the social behaviour patterns central to the spread of the HIV/Aids epidemic in the continent, particularly in sub-Saharan Africa (Walker et al., 2004).
In 2003, Sayagues (2003:4) stated that "twenty years into the pandemic, the bulk of studies and interventions have centred on women and girls.There is greater understanding of the gender dimensions of HIV/Aids but little funding and effort has gone into working with the men who interact with women and girls, as partners, husbands, fathers, teachers and so forth."A year later, Akeroyd (2004) argued for a new agenda which emphasises and focuses attention on men and their responsibilities.The author pointed out that, although Aids prevention strategies aim to alter men's behaviour to minimise the spread of the pandemic, the focus of attention is usually on women.
Other observers and analysts (Barolsky, 2003:49;Jackson, 2002:366) also began to draw attention to the deleterious consequences of this apparent gender bias which, they argued, was leading to the possible alienation and disaffection of men from HIV/Aids policy interventions and mainstreaming efforts.For instance, Barolsky and Jackson argue that while many continental and even global policy initiatives and campaigns (including the 2000 World Aids Day Campaign whose theme was 'Men and Aids-gendered approach'), do attempt to bring the role of men into their ambit, there is still an inadequate focus on this.In 2008, the UNAIDS 2008 global Aids report did acknowledge the need for programmes based on gender equity with particular attention focused on men and boys (UNAIDS, 2008:64).
In recent years however, there seems to be greater acknowledgement of the need to maintain an equal focus on interventions targeting men.For instance, new research showing that male circumcision reduces the risk of HIV transmission in men has resulted in South Africa instituting a roll out of a 'national medical male circumcision (MMC) programme', with a goal to reach 80% of men between the ages of 15 and 49 (RSA, 2011).
However, gender bias remains entrenched in mainstream policy response areas.An example is that the guideline number eight of the international guidelines for HIV/Aids and Human Rights (UNAIDS, 2006:52) stipulates that state action must provide an enabling and supportive environment for women, children and other vulnerable groups.While the 2006 UNAIDS guideline clearly defines vulnerable groups in terms transcending gender 2 (UNAIDS, 2006), a large focus of this guideline is on women.In terms of this guideline, a supportive environment is supposed to encourage the establishment of national and local forums to examine the impact of the HIV/Aids epidemic on women.States are also encouraged to champion women-centred multi-sectoral initiatives (involving the state and civil society) which should include primary health services, counselling and information on prevention, and minimising the risk of transmission in childbirth.In addition, the UNAIDS HIV/Aids human rights international guidelines contain specific human rights stipulations which pay greater attention to women (UNAIDS, 2006).In many sub-Saharan African countries gender bias in national HIV/Aids policies is entrenched in HIV/Aids policies, plans and strategies.This is referred to in a UNAIDS (2008:1) report on policies related to women's vulnerability to HIV, which indicated that sub-Saharan Africa is the most inclined to put in place policies focusing mainly on women to combat their vulnerability.

Africa's Public Service Delivery and Performance Review 59
Malawi's national HIV/Aids policy is an example.It focuses on women and girls as vulnerable groups and details a comprehensive response strategy that targets women's rights in the home and the workplace (Republic of Malawi, 2003).All South African HIV/Aids strategic plans between 2000 and 2012 have focused greater attention on women and children, especially in terms of key goals, such as reducing mother-to-child transmission, and developing and expanding care of children and orphans3 .Also in earlier strategic plans such as the 2000-2005 HIV/Aids/STD strategic plan, national indicators for monitoring programme success have been largely female-oriented.For instance, in the 2000-2005 strategic plan the first indicator which is the 'general trend of the epidemic' was measured in terms of the prevalence of HIV in antenatal visits; another indicator, 'youth', was measured in terms of the same information on antenatal visits.A third indicator, 'teenage pregnancy prevention' was measured by the number of sexually active women using condoms and, finally, another female-oriented indicator is 'abuse of women', measured by the number of reported rape cases (RSA, DOH, 2000:17).While these indicators are based on certain acceptable standards that include need, feasibility and technical merit, the fact is that women still remain the easy source for HIV/Aids generalisable statistics.However, the South African HIV/Aids 2007-2011 strategic plan (RSA, 2007) showed a more comprehensive set of indicators and measurement tools, which reflect indicators and measurements targeted at many vulnerable groups including men.
In Nigeria, one of the key HIV/Aids strategies is to promote safe sexual behaviour among women by empowering them through education and legislation to protect themselves against unsafe sex (FGN, 2003:18).The point being made here is, again, that general policies, programmes and strategies to combat HIV/Aids in sub-Saharan Africa appear to concentrate on women, virtually excluding men, even though the latter play a central role in the spread of the pandemic.Although many of the countries in sub-Saharan Africa also have national HIV/Aids policy provisions which target other vulnerable groups, such as the youth (FGN, 2003:23;RSA, DOH, 2000:25), clearly there is an absence of targeted policy responses to bring men and boys firmly into the ambit of all these policies and programmes.

CONSEQUENCES OF GENDER-BASED APPROACHES
The gender-based approach to the mainstreaming of HIV/Aids appears to have achieved significant results in many countries in sub-Saharan Africa.These policy interventions have yielded huge results as evidenced in South Africa's globally recognised successful Prevention of Mother to Child Transmission (PMTCT) programme which achieved its target of a less than 5% transmission rate (RSA, 2011).Another of these consequences is a greater general awareness and knowledge of the risks of HIV/Aids among women.This has also succeeded in fostering greater willingness among women to adopt risk-reducing activities, including getting tested for the virus, which is vital for the timely administering of the necessary medical treatments to reduce the incidence of mother-to-childtransmission.Women are therefore generally better armed with lifesaving knowledge and information on the risks of HIV/Aids than men.In addition, more and more women are acquiring a range of adaptive social skills and behaviour patterns, such as developing and/or joining women-run, dedicated social support groups and networks, and engaging in home-based care activities for their families or communities.These activities have rendered women better prepared socially and psychologically than men in terms of coping with, and adapting to living with, HIV/Aids.However, the greater focus of attention on women's health and well-being in terms of HIV/Aids policy interventions has also led to a number of burdensome consequences for women, as outlined below.

Burden of disclosure and negotiation of safer sex
In some countries, policies relating to antenatal HIV/Aids screening have made women the primary bearers of HIV/Aids status information.This is the case with Malawi's policy of HIV testing without consent for pregnant women (Republic of Malawi, 2003).This puts pressure on women and places on them the burdensome responsibility of having to disclose their HIV/Aids infections to their families and partners, often risking ostracism.Because of this policy practice in Malawi, the fear of abuse or rejection by husbands and families has caused a great deal of reluctance among pregnant women to test for HIV/Aids (BBC, 2005 http://news.bbc.co.uk/2/hi/africa/4551767.stm).However, a study in Malawi (Bobrow, 2008) on factors that influence disclosure in pregnant women showed that a huge percentage (90%) of pregnant women who become aware of their HIV positive status, tend to disclose their status to their partners.Thus, one can argue that while Malawian women are likely to disclose their status to their partners, the fear of stigma makes disclosure a burden in itself.What this means is that the success of the efforts to educate and empower women with vital Africa's Public Service Delivery and Performance Review 61 information and knowledge about HIV/Aids have also resulted in them becoming not only the bearers of the responsibility to disclose their HIV/Aids status, but also the bearers of the responsibility to negotiate safer sex as well as to educate their partners on the risks of HIV/Aids.Such a responsibility is best handled in social and family contexts, where women enjoy equal decisionmaking powers with their partners and are able to negotiate the usage of protective measures such as condoms, rather than in a situation, prevailing in many sub-Saharan countries, where women are still vulnerable to various forms of abuse and sexual violence by their partners, families and society in general.For many women in sub-Saharan Africa, such an enormous responsibility often becomes unbearable.

The burden of care and social support
Due to their greater exposure to HIV/Aids interventions and information dissemination, combined with their traditional social roles as caregivers in their families, women have also become central to caregiving for those infected and affected by the Aids pandemic (Cabrera et al., 1996).According to Barolsky (2003, 40) "instead of HIV compelling a re-examination of gender roles, the burden is being displaced vertically across generations along the female lines."In Uganda's Rakai district of about 40 000 inhabitants, there is a record of about 300-400 various women's support and home-based care groups (Cabrera et al.,.1996).In South Africa, women are more likely to be seen forming support groups and running home-based care groups.A report by the South African Department of Health (http://www.doh.gov.za/aids/)shows that in March 2003, a total of 466 home/community-based care programmes were in place, with 9 553 volunteers and 370 172 people accessing the services regularly, most of them women.This disproportionate statistic has not changed over the years as there is evidence that the major proportion of people involved in home-based care remains women as shown in several UNAIDS recent reports (UNAIDS, 2008;UNAIDS, 2012).All this serves to reinforce the idea that women have not only become resourceful in dealing with HIV/Aids, but have also come to shoulder the burden of responsibility for supporting their families and communities in coping with the pandemic, often with extremely limited resources and support from their governments.

Serving as 'guinea pigs' for information-gathering activities
Women are the sources of HIV/Aids policy-relevant data.South Africa is a case in point, where vital HIV/Aids policy indicators depend on statistical data gathered mainly from women, particularly from antenatal HIV/Aids tests, reported rape cases, reported teenage pregnancies and usage of condoms.While the latest indications show a stabilising of national epidemics and prevalence in sub-Saharan Africa and South Africa in particular, where there is evidence of a plateauing of infection rates (UNAIDS, 2008:5; RSA, 2011), HIV/Aids prevalence still tends to reflect a higher incidence among females in particular 59% in sub-Saharan Africa (UNAIDS, 2011).This article argues that perhaps a more inclusive gendered approach to policy may result in a reversal in this trend.This is because a possible unintended consequence of this greater policy focus on women could be that men become less willing -or assume that it is not necessary -to share the responsibilities and burdens of disclosure, care and prevention.It is critical for policy researchers and policy makers to understand the extent to which this inequity could be explained by referring to the seeming gender bias in HIV/Aids mainstreaming intervention strategies.Behavioural change intervention strategies in sub-Saharan Africa continue to be based on the premise that men are the primary spreaders of the virus, because of their promiscuous behaviour, without necessarily pursuing relevant and effective strategies to target them and place them at the centre of HIV/Aids mainstreaming efforts in sub-Saharan Africa.

UNDERSTANDING WOMEN'S VULNERABILITY
UNAIDS considers that vulnerability results from a range of factors outside the control of the individual, which reduce the ability of individuals and communities to avoid the HIV risk (UNAIDS, 2008).UNAIDS defines vulnerable groups as 'groups that may be disproportionately affected' by HIV/Aids, depending on the local environment (UNAIDS, 2006).These include 'women, children, those living in poverty, minorities, indigenous people, migrants, refugees and internally displaced persons, people with disabilities, prisoners, sex workers, men having sex with men and injecting drug users -that is to say groups who already suffer from a lack of human rights protection and from discrimination and/or are marginalized by their legal status' (UNAIDS, 2006:78).The relevance of looking at this definition is to appreciate that vulnerability to HIV/Aids transcends gender and thus must be a credible starting point in developing HIV/Aids policy interventions.
The social constructions of gender roles and power relations play a significant role in many countries in Africa, as they do in other countries around the world, and these have important implications, not only for domestic policies but also for HIV/Aids intervention strategies in sub-Saharan Africa.In sub-Saharan Africa, gender-based intervention strategies have tended to put women at the centre of political, social and economic policy agendas as part of broader efforts to combat the pandemic.In the course of developing appropriate national and continental HIV/Aids intervention policies, women have been prioritised, especially on the basis of a wide range of evidence, including epidemiological, which illustrates beyond doubt the disparity between women and men in terms of vulnerability to HIV/Aids infection.This is understandable and beyond debate, because of a number of critical factors that can be grouped into different categories: physiological, socio-cultural, economic and financial factors.
In terms of the physiological dimensions of the human body, the physiological aspects of women's bodies render them more susceptible to HIV/Aids infections than men.MacBride (2004) regards this as women's "greater biological susceptibility to transmission than men".For instance, a report by the United Nations (UNAIDS, 1998a:4) points to the fact that "the physiological differences in the genital tract directly contribute to women running a higher risk of acquiring HIV infection and STDs than men."The report goes on to add that "in women, many STDs are asymptomatic, so that many women are unaware that they need to seek care" (UNAIDS, 1998a:4).However, the more critical factors that render women more vulnerable to infections than men fall within the other categories identified above -socio-cultural, economic and financial -and these are well documented in literature and numerous reports produced by a wide range of organisations internationally and on the African continent.For instance, Gupta (2000) provides an outline of a range of sociocultural, economic and financial circumstances shaping women's experiences in a number of countries in Africa, thus rendering them more vulnerable to infections.Also, the UNAIDS fact sheet on women, girls and HIV (UNAIDS, 2011) shows that inequalities which exist culturally and socio-economically, such as denial of property and inheritance rights for women and early marriage, all contribute to shaping women's experiences in sub-Saharan Africa.
Gupta also argues that dominant cultural beliefs in many countries on the continent imply that 'good' women are ignorant and less informed about sex in general, as they are usually assumed to be more circumscribed than men in their sexual behaviour and experience (Gupta, 2003:3).Consequently, they are not expected to be knowledgeable about the 'risks reduction' behavioural aspects of their sexual interactions with men.As a result, well-informed women tend to feign ignorance of this knowledge and usually adopt passive attitudes during sexual interactions, which prevent them from adopting proactive attitudes to negotiating safe sex (Gupta, 2000:3).Gupta lists a number of other cultural norms and traditions in many societies on the continent that increase women's vulnerability to infections.For instance, widespread traditional normative expectations or assumptions of young girls' virginity, which prevents them from acquiring information about sex, lest they are assumed to be sexually active; strong norms and traditions of female sexual passivity combined with economic dependence on men, which reduces their ability to negotiate safe sex options; and violence against women.
Finally, UNAIDS also points to how even the advancement in prevention technology, in the form of female condoms, has to face the problem of genderbased cultural obstacles.The report points out that for many cultures "condoms are associated with illicit sex and STDs, and women who attempt to introduce them into a relationship encounter problems such as being perceived as unfaithful or 'over-prepared'" (UNAIDS, 1998a: 9).

HIV/AIDS AND MEN'S VULNERABILITY
As already argued, the greater vulnerability of women to HIV/Aids infections has influenced and shaped policy responses in such a way that women have become the primary targets of national and continental policy actions.Men, on the other hand, are not as central to intervention strategies, and while behavioural change messages do focus some attention on men, these do so predominantly in the context of men being identified as the 'perpetrators' (spreaders of the virus) and culprits, rather than as vulnerable groups, even if less so than women.
However, a small but increasing number of studies (see Peacock & Levack, 2004;Mutonyi & Greig, 2002;Gupta, 2000;Cornell, 2003) on the continent are beginning to focus greater attention on the situation of men, especially in terms of the nature of their socialisation into specific roles and attitudes, and the way these have contributed to their vulnerability to HIV/Aids infections.These studies are seeking ways to understand the complexity of men's social and cultural realities in order to contribute comprehensive behavioural intervention strategies and policies to address the situation of men in sub-Saharan Africa, particularly with regard to issues of men's sexual behaviour and the social and cultural norms and traditions that underpin these persisting behavioural patterns.For instance, Peacock and Levack's research into the Men as Partners Program in 2004 showed that the work of this local NGO in collaboration with other civil society networks makes men the central target of workshops and Africa's Public Service Delivery and Performance Review 65 programmes aimed at "changing knowledge, attitudes and behaviour; mobilising men to take action in their own communities" (Peacock & Levak, 2004:175).Also, South Africa's 2007-2011 strategic plan calls for "a comprehensive package that promotes male sexual health" (http://www.tac.org.za/documents/NSP-Draft10-2007-2011.pdf).UNAIDS's latest report calls for a scale-up of programmes based on gender equity, with particular attention focused on men and boys (UNAIDS, 2008:64).Zambia's growing emphasis on the situation of men and boys is evidenced by the growth of male caregivers in Zambia's Kara Counselling Centre, which works with local chiefs and church elders (Sayagues, 2003).
Despite these developments, dominant policy paradigms, not only in the literature but also in public debates, about the role of men in society in general and in the spread of the HIV/Aids pandemic in particular, serve as a critical obstacle to our ability to perceive men as a possible vulnerable group.While it is essential and justifiable that current policies and programmes proceed from the idea that men are crucial in the spread of the pandemic, strategically this should be reflected in terms of behavioural change intervention strategies and programmes specifically targeted at them as a group.
In other words, the fact that men are also vulnerable to infections, due to a number of important factors outlined below, needs to be made an integral part of policy responses to the pandemic.That this is not is an important aspect of current policy responses in many countries in sub-Saharan Africa, whether due to deliberate neglect or not, tends to lead to HIV/Aids intervention strategies that gloss over the realities of African men, constructing their behaviour in a manner that decontextualises them from their social, cultural, economic and even historical circumstances.
For purposes of analysis, the subsections that follow will explore a number of factors that render men vulnerable to HIV/Aids infection.These factors will be categorised into three groups: socio-cultural, economic and financial.The literature also makes reference to political and historical factors that contribute to men's vulnerability to HIV/Aids infections.

Socio-cultural factors leading to men's vulnerability
Before any strategy aimed specifically at the situation of men in sub-Saharan Africa could be formulated and put in place, a critical paradigm shift will be necessary.Policy makers and strategists would have to begin perceiving men and boys as more than just the culprits and perpetrators in spreading HIV/Aids.They would have to also be perceived and treated as a vulnerable group -66 Gender and HIV/AIDS vulnerable to HIV/Aids infections.For instance, a UNAIDS report (1999) identifies traditional norms of masculinity prevalent in many sub-Saharan countries as problematic.In terms of these norms, men are expected to be well informed, knowledgeable, and experienced in matters of sex, which in turn prevents them from admitting their ignorance about matters of sex and risky sexual behaviour, thus preventing them from seeking help and information on how to avoid risky sexual behaviour.Gupta et al. (1994) point to traditional beliefs in many societies which encourage men to have multiple partners as a sign of manhood, which in turn undermines messages of abstinence and faithfulness to change behaviour.This places men and boys at risk of infection.A UNAIDS report (1999) also draws attention to the traditional norms of masculinity in many countries, in terms of which sexual domination of women, combined with sexual aggression and sometimes coercion and violence, are considered vital aspects of men's sense of power and control.Richter and Morrels's edited work, Baba: Men and fatherhood in South Africa, gives some insight into men's feelings of disempowerment in their experiences of poverty, incarceration and unemployment in South Africa (Richter & Morrel, 2006).These factors, combined with drug and alcohol abuse, invariably place men and boys in situations where they are exposed, and therefore rendered extremely vulnerable, to HIV/Aids infection.

Economic and political factors leading to men's vulnerability
Bringing men effectively into mainstream HIV/Aids policy responses and intervention strategies must be accompanied by a paradigm shift that constructs a different role for men as more than mere spreaders of the pandemic.Men also have to be viewed as partners in the fight against HIV/Aids.But more than that, it is critical that men are also seen as a vulnerable group.As Oppong and Kalipeni (2004) argue, this will entail targeting men's behavioural change within the wider context of the macro-economic and political environment, in addition to the socio-cultural factors as outlined in the previous subsection.
The broader negative macro-economic context in sub-Saharan Africa has created widespread problems of economic deprivation, unemployment and inequality in many countries.This serves as a context and backdrop to what risky sexual behavioural patterns among men and boys have developed, and therefore needs to be understood by policy makers.In particular, the devastating economic collapse in Zimbabwe and the grinding poverty in other countriessuch as Lesotho, Swaziland, Malawi, Zambia and Mozambique -and war and conflict in several other countries including the Democratic Republic of Congo (DRC), have led to the widespread phenomenon of economic and political migration in sub-Saharan Africa.A study on the Zimbabwean male psyche with respect to reproductive health, HIV/Aids and gender issues suggests that there is a relationship between levels of education and income bracket and men's perceptions of sexual roles, pointing to negative sexual convictions which may harm women (Chiroro et al., 2002).
In South Africa, the history of legalised racial inequality, enforced economic deprivation, forced removals of whole communities from economic nodes and the resultant internal economic migration, have made the disparity in wealth between the rich and the poor in South Africa one of the highest in the world.For instance, in 1993 the richest 10 per cent of the population in South Africa received 47.3 per cent of the national income, while the poorest 40 per cent received only 9.1 per cent.The internal economic migration and social displacement of the economically active population in South Africa, exacerbated by rapid levels of urbanisation and high rural-to-urban migration, have also created conditions that are highly conducive to the ceaseless spread of HIV/Aids.While no research has conclusively linked gender violence in post-apartheid South Africa to the emergence and promotion of women's rights and emancipation through legislation and policy, it is suggested that perceptions among men of their traditional roles being undermined or disrespected by women, may lead to negative reactions and mistreatment of women.
The impact of these broader macro-economic and political factors (including conflict and war) has been to compel men and women in many countries in sub-Saharan Africa having to leave their families and communities to seek employment opportunities or safety in the cities and/or other countries.The resultant refugee populations or migrations across towns, cities, regions and the continent are the creation of migrant populations of men and women, many of whom have been socially displaced from their families and social support networks, leaving them exposed to risky social behaviours, especially in cases where women and girls turn to sex work to support themselves (UNAIDS, 1997; UNAIDS, 1998b).In addition, men in sub-Saharan Africa are usually engaged in a range of highly mobile (and sometimes transitory) economic activities, such as trucking or mining.The UNAIDS best practice collection on HIV (UNAID 1998b) points out the vulnerability of the men in the military, and identifies vulnerability factors such as military risk-taking culture and attitudes to civilian populations which often expose them to risky sexual behaviour, thus rendering them vulnerable to infections.

Gender and HIV/AIDS CONCLUSION: TOWARDS A GENDER-BALANCED APPROACH
There are indications that men's vulnerability is becoming a policy focus as seen in the draft 2012-2016 South African strategic plan (RSA, 2012) in which key HIV/Aids policy target populations include track drivers, mine workers, clientele of taverns and shebeens, people living in unstable communities and men between the ages of 12 and 49.However policy and programme interventions in many countries in most sub-Saharan African states show a pattern which prioritises women over men, thus allowing men to fall through the cracks.Understandably, the premise from which policy makers and activists in this field proceed is to focus greater attention on women and girls, as they are perceived to be the most vulnerable group.
This article has argued for the need to revisit the gender approach to HIV/Aids as it presently exists.The current approach, which targets women's rights, empowerment and the mainstreaming of women's issues into HIV/Aids policy and legislation should be balanced by an equally aggressive action that directly targets issues of concern for men, especially their health, rights, empowerment and education, particularly in the context of the pandemic.It is therefore necessary for policy research to problematise HIV/Aids policy approaches that tend to marginalise and neglect the situation of men, especially as they are the main spreaders of HIV/Aids.It is critical for policy responses to the pandemic to ensure that men become as much the focus and targets of policy responses as women, if not more so, given the important role that they play in the spread of the disease.
Prioritising the situation of men in sub-Saharan Africa means having to address issues such as improving men's access to health infrastructure and support services relating to men's reproductive health.Additionally, it will be important to shift interventions towards long-term and viable strategies that focus attention on factors that perpetuate the spread of HIV -for instance by addressing poverty and unemployment, and internal and regional migration, with particular emphasis on displaced men and women.The need to ensure universal education for boys and girls, as well as building and upgrading the economic infrastructure, is critical.It is also important to encourage and create an environment for debate and dialogue, particularly within men's social networks, to bring communities together to mobilise through strong male community structures and opinion groups.This will entail, among other things, extending HIV/Aids experiences and research to incorporate men's stories, as well as projects, programmes and campaigns that are mainly targeted at men.Finally, in the long term a continuous commitment by the state and other Africa's Public Service Delivery and Performance Review 69 stakeholders, such as community-based organisations, traditional leadership structures and civil society, to addressing poverty reduction, education and unemployment will provide a more holistic and integrated strategy that will help stem the tide of HIV/Aids in sub-Saharan Africa.

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