Meet & Greet: Alfred Adams, researcher MaxART

November 9, 2014

“I want to be a voice for men”. Alfred Adams (28) is a medical anthropologist from Swaziland. In the context of the MaxART programme he has conducted qualitative research on the low utilization of services by men in Swaziland. On a rainy day in Amsterdam, we talk about male involvement and his research findings. “When it comes to HIV, statistics show that men hardly test compared to women. So that is a big problem. If we want to reduce the number of new HIV infections, we need to make sure that we reach out to the men.”

What is the scope of your research?

My research focuses on men’s health, and in particular on men’s uptake of two new HIV prevention technologies: voluntary medical male circumcision and treatment as prevention. Men have been known to underutilize health services in general. If men do not test, they end up with a higher viral load and unknowingly transmit HIV to their partners. So that is a big problem. But also beyond testing and treating, male circumcision reduces men’s chances of acquiring HIV, which in the long term reduces infections. So that’s basically my scope of study. Now, I am here in the Netherlands to write up my findings. I expect to finish my PhD next year.

What are the main findings from you research?

Issue of masculinities
The most salient barriers to men’s uptake of services, the issue of masculinities, have never been studied in Swaziland. One of my participants said: ‘a real Swazi man is someone who has a wife, kids, and who is able to take care of them’. They argue that circumcision is a direct threat to their manhood. From rumours they heard that it could reduce your sexual activity if you do it at an older age. Also, the possibility of complications, is a barrier. On top of that, circumcision is 60% protective. So men feel it is useless, as you still need to use condoms. It didn’t make sense to them. These are simple reasons for low uptake of services by men, and it is so important.

Men have been left out ever
Most HIV prevention interventions have been focussing on women. Men have been left out ever, and still they find they don’t belong to clinics. This means they also lack good information, as that is also often provided in the clinic. Knowledge is power, and there are many misconceptions among HIV tests and treatment. Lack of information is a big limitation. 

Poor design of clinics
In many clinics, separate structures have been set up, for instance a service for VCT (voluntary counselling and testing) next to the clinic. That backfires somehow, because whenever you go there it is obvious that you are there for either testing or getting treatment. That kind of set up on its own is very poorly designed. 

Issues of confidentiality
Also, what you find is that the clinic employees are staying within the community. Very often, nurses and counsellors are part of the community. This makes it hard for men to reach these facilities. They fear confidentiality issues. Those factors are a huge hindrance.

What do you think is needed to overcome these barriers?

It is not that men don’t want to go for services. They care about their health, they want to maintain strong and healthy. They do go, but they do it in a way they feel is appropriate to them. We need to accept that and work with that. We really want to make an impact. We need to understand men and change our approach.

If we want to reach men, we should go where the men are. Don’t take them to the clinics. In the MaxART programme, male focused health days were designed to increase uptake, but it was difficult. Sometimes even 20 men came to the clinic, but you found that only one took an HIV test.

A good example is door-to-door testing. One of the difficulties though is that men move around the country, looking for jobs. They have a high social and economic burden. But we had strategies to find them. I was involved in a project where we went door-to-door and found their partners, their children, and we asked them how to reach their men.  We tried to work around the men’s schedules, so we had to work on weekends as well. So it is possible. We increased uptake. 

You have spoken to many men, can you think of one person who made a deep impression on you?

Actually, I think of a woman [laughs]. This lady is a nurse who also works as a traditional healer. Most men like going to traditional healers. One of the reasons is that there is confidentiality. They offer all kind of services, so nobody knows why you are there. So this lady told me both sides of the coin. She believes that men like to start with traditional healing. Then, as an illness needs biomedical treatment, they can go for biomedical healing. 

Traditional healers can work hand in hand with biomedical doctors and with the Ministry of Health. As Africans we have been using traditional medicines for a very long time. We believe in this. You cannot just ignore this. So if we don’t involve such a big therapeutic institution, we are missing out.

What are you most proud of, when it comes to your research and your findings?

I can only be proud if my research has an impact. I want to be a voice for men. If you check literature on African masculinities, men are blamed for the spread of HIV, because they are considered promiscuous and they possess too much power in relationships. But they are highly affected. When it comes to HIV there is high morbidity and high mortality among men. 

This year, Swaziland hosted the first men’s health month ever in the country. For me it was successful because it has never been done before, it was covered by the media and there were quite some men. This made me happy and proud.

Alfred Adams works as a researcher for MaxART: Maximizing ART for Better Health and Zero New Infections in Swaziland, a unique package of interventions aimed at addressing the remaining barriers to HIV testing, care and treatment and further strengthening the collective efforts of the many involved programmes and partners in the country. MaxART is an initiative of Swaziland’s Ministry of Health, STOP AIDS NOW! and the Clinton Health Access Initiative. The programme partners include the Swaziland Network of People Living with HIV and AIDS (SWANNEPHA) and the Global Network of People Living with HIV (GNP+), the National Emergency Response Council on HIV/AIDS (NERCHA), national and international non-governmental organisations including the Southern Africa HIV & AIDS Information Dissemination Service (SAfAIDS), social scientists from the University of Amsterdam and researchers from the South AfricanCentre for Epidemiological Modelling and Analysis (SACEMA).

This meet & greet has been published in the STOP AIDS NOW! e-news November 2014