Blog: Masculinities, tobacco use and ART adherence

By Frances Thirlway and Noreen Mdege 

People living with HIV are more likely to use tobacco than the general population even though smoking makes them vulnerable to opportunistic infections. Our recent study explored patterns of tobacco use among adults receiving antiretroviral treatment (ART) in Uganda. Here we discuss some of our findings in relation to the wider literature on masculinities in Sub-Saharan Africa.

Smoking cessation in the context of HIV can be seen as a sub-category of adherence to antiretroviral treatment (ART); in return for their care, people living with HIV are required to take their medication as prescribed and adopt ‘responsible lifestyles’, including avoiding alcohol and tobacco. This may be one reason why men in Sub-Saharan Africa are much less likely than women to get tested and to access HIV care. ‘These drugs deprive us of fun’, they complain.

Contrasting masculinities 

Discussions of masculinity in the context of HIV have focused on hegemonic masculinity and its association with risky sexual practices and HIV transmission, particularly the literature focused on South Africa. However, we found that men on ART were pulled between two contrasting registers of masculinity. Siu has described these as ‘respectability’  - being a good husband and father, adhering to ART -  versus ‘reputation’  - sexual prowess, alcohol consumption etc. 

Siu’s reputation/respectability dualism, which builds on anthropological studies of the Caribbean, provided the basis for our model of barriers to and facilitators of smoking cessation. Sociable ‘reputational masculinity’ made it difficult for our research participants to stop smoking. It involved pressure to share and enjoy tobacco with others, occupational norms of tobacco use and a legacy of advertising messages, connecting tobacco with physical strength. 

On the other hand, family support to quit bolstered adherence through an appeal to ‘respectable masculinity’. Participants described tobacco cessation as being both explicitly supported by family members and motivated by their own desire to provide for their families. But respectable masculinity was not available to everyone: men who were socially isolated or in precarious employment could not measure up to the ideal of supporting themselves let alone a family. Instead, they used tobacco to escape anxiety and depression caused by food insecurity, falling back on reputational masculinity and getting validation through smoking and drinking with their peers.

De-colonising approaches

Siu’s model of respectable/reputational masculinity has seen some take-up in the literature on ART adherence to HIV treatment and the ‘missing men’ of ART, but not in the gender and health literature, which argues that gender relations and ideals need to change in order to improve health, particularly in Sub-Saharan Africa. And yet Siu’s model, with its focus on the masculinity ideals available to men and the economic and political factors which create or constrain that availability, is surely more generous-spirited than approaches that require subordinated men to carry the burden of increasing gender equality. Interventions to change masculinities must also question the hegemonic masculinities enacted by governments and transnational corporations, address economic marginalisation, and foreground de-colonising approaches and post-traumatic analysis.