Male Youth and Voluntary Counseling and HIV-Testing - The Case of Malawi and Uganda

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Male youth and Voluntary Counseling

and HIV-Testing: the case of Malawi and
Uganda
a a a
Chimaraoke O. Izugbara , Chi-Chi Undie , Netsayi N. Mudege &
a
Alex C. Ezeh
a
African Population and Health Research Center, Shelter Afrique
Center, Nairobi , Kenya
Published online: 12 Aug 2009.
To cite this article: Chimaraoke O. Izugbara , Chi-Chi Undie , Netsayi N. Mudege & Alex C. Ezeh
(2009) Male youth and Voluntary Counseling and HIV-Testing: the case of Malawi and Uganda, Sex
Education: Sexuality, Society and Learning, 9:3, 243-259, DOI: 10.1080/14681810903059078
To link to this article: http://dx.doi.org/10.1080/14681810903059078
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Sex Education
Vol. 9, No. 3, August 2009, 243–259
Male youth and Voluntary Counseling and HIV-Testing:

the case of Malawi and Uganda
Chimaraoke O. Izugbara*, Chi-Chi Undie, Netsayi N. Mudege and Alex C. Ezeh
African Population and Health Research Center, Shelter Afrique Center, Nairobi, Kenya
Downloaded by [Istanbul Universitesi Kutuphane ve Dok] at 01:11 21 December 2014
There is limited research addressing the beliefs of adolescents related to Voluntary

Counseling and HIV-Testing (VCT). This paper analyzes qualitative data on such
beliefs elicited from male youth in Uganda and Malawi. Although study participants
understood the mainstream public health rhetoric on VCT, much of their narratives
framed going for HIV testing in terms of danger, as a sign of lack of self-confidence,
and as an acknowledgment of vulnerability. This tendency, we contend, is strongly
rooted in the inclination of male youth to perform and validate their identities in
gestures of self-certitude, imperviousness, invulnerability, and invincibility. Further,
the idea of ‘not wanting to die alone’ from AIDS also featured prominently in the
narratives, with many respondents declaring that they would deliberately infect others
with HIV should they test positive. Key to freeing young people from the shackles
of consternation and misconceptions about VCT and HIV is comprehensive HIV
education.
The problem
Voluntary Counseling and HIV-Testing (VCT) is a process in which an individual
undergoes counseling, enabling him or her to make an informed choice about being tested
(World Health Organization 2002; UNAIDS 1997, 1999, 2000a; Pool, Nyanzi, and
Whitworth 2001; Ekanem and Gbadegesin 2004). A multitude of sources (including
UNAIDS 2000a; Enosolease and Offor 2004; Voluntary HIV-1 Counseling and Testing
Efficacy Study Group 2000; Olley 2006) suggest that VCT must not only be entirely the
choice of individuals, but that individuals seeking HIV testing must also be assured of the
confidentiality of the results. Currently, VCT is celebrated as a very critical and
cost-effective tool for the screening, prevention, and control of HIV in Africa. It is key to
the success of interventions aiming to prevent mother-to-child HIV transmission.
By providing information on the sero-status of pregnant mothers, VCT has saved the lives
of several thousand newborns in Africa. The positive role of VCT in promoting sexual
behavior change is amply documented. Akerele, Abhulimen, and Okonofua (2002)
reported a 40% reduction in unprotected sex among individuals who underwent VCT,
compared with those who only received health information.
Families and communities also benefit from VCT. Ekanem and Gbadegesin (2004)
argue that the early detection of HIV can permit advance planning for the livelihood and
financial security of survivors and dependants. Communities reap huge benefits when their
members feel safe enough to be open about HIV and their own statuses, and become
involved in the fight against the disease. Such first-hand experiences not only help
*Corresponding author. Email: coizugbara@yahoo.com; cizugbara@aphrc.org
ISSN 1468-1811 print/ISSN 1472-0825 online

q 2009 Taylor & Francis
DOI: 10.1080/14681810903059078
http://www.informaworld.com
244 C.O. Izugbara et al.
communities engage with the epidemic, but also prompt policy-makers to face up to the
pandemic (Kalichman and Simbayi 2003; Kawichai et al. 2002; Ekanem and Gbadegesin
2004; UNAIDS 1999, 2001; Nyablade et al. 2001). VCT can be key in prolonging the lives
of people infected with HIV (Zachariah et al. 2003). Premarital VCT also prevents the
vertical and horizontal transmission of HIV (McKillip 1991; Cleary et al. 1987; Altman
et al. 1992). Recognizing the critical role that VCT can play within a comprehensive range
of measures for HIV/AIDS prevention, control, and support, UNAIDS has recommended
its mainstreaming into national HIV/AIDS policies and programs (UNAIDS 1999, 2001).
The bulk of extant VCT research in sub-Saharan Africa has emphasized its
acceptability as well as people’s willingness to undergo it. These studies have focused
largely on adult men and women, seeking primarily to link their VCT-related attitudes and
perceptions to specific variables such as marital status, knowledge of someone infected
with HIV, involvement in risky sexual practice, beliefs about HIV, occupation, gender,
knowledge about mother-to-child HIV transmission and prevention, sexual history and
behavior (Enosolease and Offor 2004; Misiri, Tadesse, and Muula 2004; MacLean 2004;
Kalichman and Simbayi 2003; Akpede, Lawal, and Momoh 2002; Kipp et al. 2002;
Izugbara 2002; Nyablade et al. 2001; Killewo et al. 1998). Preoccupied with the
quantitative relationships between the above variables and VCT-related attitudes and
behaviors, researchers have neglected the critical qualitative voices on VCT.
Consequently, questions about the complexities of experiences, views, meanings, and
beliefs surrounding VCT have failed to receive systematic attention (Castle 2003; Nuwaha
et al. 2002; Maman et al. 2001; Yoder, Matinga, and Matinga 2004). Further, the adult-
centered character of existing research on VCT research has hampered knowledge on
young people’s views surrounding VCT. As a result, adolescent VCT-related beliefs and
views have remained un-interrogated. However, sub-Saharan African adolescents remain
not only critically at risk for HIV infection but can also benefit immensely from VCT. A
host of authoritative and recent sources (including the Voluntary HIV Counseling and
Testing Efficacy Study Group 2000; UNAIDS 2001; Enosolease and Offor 2004; Amusa
et al. 2004) suggest that VCT offers a window of opportunity for snatching young people
from HIV infection and for helping infected youth to live longer and perhaps more happily.
Focusing on Uganda and Malawi, which are among the world’s most AIDS-afflicted
countries (Yoder, Matinga, and Matinga 2004; National AIDS Commission of Malawi
[NACM] 2001; UNAIDS 2000, 2006; Nuwaha et al. 2002; Uganda HIV/AIDS
Commission 2007, Pool, Nyanzi, and Whitworth 2001; UNFPA 2006) and where young
people continue to face a growing risk of HIV infection (World Health Organization 2002;
UNAIDS 2005, 2006; Bankole et al. 2007), we examine young males’ views and talk
about VCT in group interviews. Among other things, we probe the particular role
of masculinity in the uptake of and attitudes toward VCT among male youth.
The implications of gender scripts for the uptake of and willingness to undergo HIV testing
remain ignored in the literature. Our central thesis, simply put, is that the inclination of
male youth to perform their masculinity in gestures of self-efficacy, imperviousness,
invulnerability, and invincibility and to present themselves as emotionally detached,
unshakable, and fearless about otherwise risky and uncertain situations is key to making
sense of their apprehension about VCT as well as their reluctance to get tested.
Adolescent narratives surrounding VCT offer a unique and necessarily critical insight
into what they believe and do (Eyre, Davis, and Peacock 2001), and could be instructive
about what the future holds for the use of VCT in the fight against HIV and AIDS in
Africa. Lay discourses of critical health practices have immense theoretical and practical
salience (Kaddour, Hafez, and Zurayk 2005; Obermeyer 1999). More recent public health
Sex Education 245
studies highlight the importance of engaging the prescriptive images of a target

population’s beliefs with a discourse that objectively grounds the concerns, views, and
realities of expected beneficiaries of health interventions and actions (Yoder 1997;
Izugbara 2007). The importance of work with younger males, particularly in the field of
risk and prevention, has also been recognized (Mundigo 1998; Social Science and
Reproductive Health Research Network 1999, 2001; UNFPA 1995; Wainerman 1998).
The emic (insider) perspectives of young male adolescents on sexual health issues are key
to the creation of policies that will suit their needs. They hold forth immense potential for
addressing some of the world’s most pressing health concerns, including HIV, and for
shaping understandings of the issues affecting young people in the current move towards
global health sustainability – most currently typified by the UN Millennium Development

Goals (United Nations 2005).
The research described here injects the missing qualitative voices of vulnerable young
males on VCT in two Sub-Saharan African countries ravaged by AIDS. Aiming to offer
a youth-centered perspective on the matter, we focus on young men as active agents,
exploring the implications for their VCT-related beliefs and views, of their identities as
males. The focus here on how young men navigate and deploy their identities and
masculinity as they relate with HIV services, including VCT, is key, and clearly highlights
the need for intervening directly with boys and men if the issues that continue to put them and
their partners at risk are to be sustainably addressed (Smith 2007; Izugbara 2005a, 2005b).
Data sources
Focus group discussion (FGD) data from the Protecting the Next Generation (PNG)
project are used in this study. The PNG is a multi-country study conducted between 2002
and 2006 by the Guttmacher Institute and its partner research institutions, including the
African Population and Health Research Center. The study sought in-depth information on
the factors that put young people in Sub-Saharan Africa at risk for negative sexual and
reproductive health outcomes especially HIV/AIDS, other sexually transmitted infections,
and unwanted pregnancies. Four countries – Burkina Faso, Ghana, Malawi, and Uganda –
were covered in the study. Altogether, the study involved 55 FGDs with 14– 19-year-olds
and 400 in-depth individual interviews (IDIs) with 12 – 19-year-olds. A further
representative survey of 12– 19-year-olds and 240 IDIs with parents, teachers, and health
providers were conducted in each of the countries.
The present paper, however, only relies on data from 11 FGDs conducted by young
male adults, with male youth in rural and urban Uganda and Malawi. Reflecting on key
methodological issues thrown up in the PNG study, Undie, Crichton, and Zulu recently
stressed:
A review of the FGD and IDI transcripts showed that young people were more comfortable
discussing . . . in peer focus group discussions than in in-depth interviews, supporting findings
from other settings on the usefulness of FGDs for investigating sensitive or personal issues
that are easier to discuss in a group setting, with a ‘group’ (as opposed to ‘personal’) focus.
The FGDs thus (proved) more fruitful . . . than the IDIs . . . (2007, 225)
FGD question items addressed themes including perceptions of sex, VCT, the nature of
adolescent sexual relationships, their partners and strategies for securing sexual
partnerships. Other issues covered include knowledge related to HIV and STI and
views on abstinence, condoms, and premarital pregnancy. Information was also sought
on what young people know about sexual and reproductive health services as well as
their preferences regarding those. However, the current study only analyzes information
provided by the respondents on VCT. This included what they know about VCT, whether
they consider VCT services to be accessible to them, their views about the importance or
otherwise of getting tested, and their narratives surrounding the implications of VCT for
HIV. Male youth involved in the study varied on the basis of age, place of residence, and
schooling status.
All interviews were audio-taped, transcribed, and translated verbatim from local
languages into English with the help of the field assistants. ‘Immersion in the data’ (Burnard
1991; Waskul, Vannini, and Weisen 2007) was achieved by reading the transcribed texts
over and over again. Following these readings, memos were developed on themes arising
from the data. Contents of the memos developed from the data were analyzed relying on
grounded theory (Glaser 1992). In many instances, verbatim quotations are used to illustrate
young peoples’ responses on relevant issues and themes. Key limitations of the present
study include that it relies only on data collected from male youth. Juxtaposing the views of
male and female youth on VCT would yield more critical insights on the matter of gendered
narratives about VCT. The FGDs with male youth were also facilitated by male interviewers
only. The impact of this all-male space on the responses elicited is currently unclear.
Findings
VCT-related knowledge
VCT offers an effective means for both secondary and primary prevention of HIV.
It decreases both the likelihood that HIV-positive people will infect others and that of
uninfected people engaging in risky sexual behavior. Realizing this, the promotion of
public awareness and utilization of VCT has remained a key component of HIV prevention
programs in Uganda and Malawi (NACM 2003; Uganda HIV/AIDS Commission 2004).
Narratives from the present study indicate high-level awareness, among participating male
youth, of the prevailing public health discourse on VCT. They were fully aware of the
existence, purpose, and uses of VCT services. Noteworthy, however, is that much of what
the male youth knew about VCT was not based on personal experiences of getting tested,
but on secondary sources, especially the mass media. In none of the FGDs did any
participant admit to seeking HIV testing or even to knowing male peers who had tested for
HIV. Nonetheless, they still spoke knowledgeably and eloquently about VCT. Evoking
arguments that were typical of the views elicited in the FGDs, a Malawian respondent
declared: ‘We all know about VCT, but for some reason, there is hardly anyone of us who
gets tested . . . ’. Although the narratives revealed their awareness that VCT services were
free and available in many places, it is significant that only a few of the respondents
expressed willingness to undergo VCT. Participants also knew that pregnant women and
couples looking to get married were frequently required to go for VCT and demonstrated
high-level knowledge of governmental and non-governmental organizations – churches,
clinics, civil society institutions, community-based groups, and even research centers –
that offer free or sometimes cheap VCT services in their communities. A Malawian male
underscored this point thus:
There is a certain club at Mkanda which sensitizes people on VCT . . . They take your blood
samples and send them to the central hospital at the district where the blood is tested and
(when) the results are out, you go and collect from them . . .
Participating males from both countries knew specific days during which some
organizations and clinics in their communities offered free VCT. In Malawi, a respondent
spoke of clinics and hospitals that offered free VCT services on Fridays while a Ugandan
Sex Education 247
respondent admitted that ‘Even if you go to KCC (Kirokole City Council Clinic) four
times a day for VCT, they cannot send you away’. The respondents were aware of the
critical features of VCT services, especially confidentiality and the fact that it must be
entirely the choice of the individual. A Ugandan respondent thus noted that VCT involves
‘going to test voluntarily. They test you, counsel you and tell you how to live’. In Malawi,
it was also pointed out that VCT involves ‘going to be tested for HIV without being
forced’.
Awareness of the counseling component of VCT was also high among the respondents.
Counseling reportedly preceded and followed the actual HIV testing. The purpose of the
pre-test counseling was described as including making VCT seekers understand the
importance of testing, while post-test counseling enlightened the HIV-infected about how
they could live longer and those who test negative on how to continue protecting
themselves. A Ugandan respondent aptly made the point that ‘after the VCT, if you have
HIV, they will counsel you, and you will be firm and plan for your future. But if you don’t
have the disease, they will encourage you to continue to avoid it’. A similar refrain echoed
through the FGDs with Malawian youth: ‘When you go to the blood testing services and
you’re told that you do not have the virus, they also advise you to go home and continue to
keep yourself safe’. Yet another Malawian interlocutor maintained that people who test
positive ‘also receive advice on how to live. If the boy used to be promiscuous he would be
told to change his behavior so that he should not infect others’.
Sources of information on VCT reported by the respondents included radio, television,
peers, religious leaders, school-teachers, health seminars, workshops, community health
educators, and service providers. However, as earlier argued, high-level awareness of the
availability and usefulness of VCT notwithstanding, young males in the survey had yet to
undergo VCT. Furthermore, they did not display a positive disposition toward doing so. In
the section that follows, we demonstrate that young males’ consternation with VCT and
reluctance to seek it stem primarily from a complex web of socio-cultural and economic
factors, particularly their identities as males.
Young people and VCT: constraints and acceptability

Frequently referring both to what they knew about their peers as well as their own lived
experiences, male youth in both countries reported numerous barriers to their uptake of
VCT services. Available narratives suggest that they faced spatial, economic, and social
barriers in accessing VCT services. Key among these barriers were, however, the
respondents’ anxieties about their identities as males, specifically in the context of critical
gender scripts that frame maleness in terms of self-efficacy, emotional control, and
imperviousness (Burns and Mahalik 2007). In several current sociological, psychological,
and anthropological studies, vivid descriptions of young males’ struggles with healthcare
services have emerged. In these studies, the logic of invincibility, self-confidence,
self-certitude, and invulnerability looms large as a major deterrent to the uptake of health
services by men and boys (McCarthy and Holiday 2004; Mahalik et al. 2003; Mahalik,
Good, and Englar-Carlson 2003; Mahalik, Lagan, and Morrison 2006; Pleck, Sonenstein,
and Ku 1994; Padesky and Hammen 1981).
Going by the information elicited, a key barrier both to VCT uptake and to
positive attitudes toward VCT among male youth in the study was the male ideology of
self-certitude. Self-certitude as a masculine gender ideology encourages and expects men
and boys to carry on with confidence and resolve, even in the presence of contradictory
evidence or when they have very little reason to do so (Izugbara 2008). Support for the
above claim inundates the study narratives in many ways. A critical and commonly
mentioned reason given by responding male youth for not seeking VCT was that they were
sure that they were uninfected, even though they themselves frequently admitted to
regularly walking badly (engaging in risky sexual practices). In several instances,
respondents argued that they risked becoming infected with HIV in the course of testing,
with several of them claiming knowledge of people who have suffered such a fate. Being
certain of their own negative HIV status, they considered going for HIV testing to be
very risky.
In Malawi, respondents had heard of young boys and girls, married women and men,
as well as pregnant women, who got infected while using VCT services. One of them
maintained that he would not go for HIV testing to avoid suffering a similar fate. Clearly
demonstrating the influence of the gender ideology of self-certitude, the respondent in
question noted that he was cocksure of his HIV-negative status and would not want to
‘be infected by VCT service providers’. Worthy of emphasis here is that this decision
was not due to this respondent’s non-involvement in risky sexual behaviors. Rather it
was, as he admitted, because he knew himself and was ‘sure that he was not infected’.
Another Malawian participant noted that male youth like him do not go for VCT because
‘they believe in themselves’. Doubting that people who ‘know themselves go for HIV
testing’, he also underlined the risk of ‘getting infected with HIV during VCT’ as a key
deterrent to the uptake of VCT by male youth. We was persuaded that VCT service
providers frequently use infected needles to draw blood for the tests’. FGD narratives in
Uganda also revealed very similar sentiments: boys were spoken of as people who do not
have to go for VCT because they ‘knew themselves’, ‘were sure of themselves’, and also
because they ‘worry that the instruments might infect them with HIV’. In clear
affirmation of this personal feeling of invulnerability and self-efficacy, a participant from
Uganda stressed that ‘ . . . like me, I know I am okay but on going there [that is, to VCT
providers] they might tell you that you are positive, that you have the virus, they make
mistakes’.
Evidence from the study also suggests that the uptake of VCT by Ugandan and
Malawian male youth is deterred by the male ideology of invulnerability and emotional
control. Many studies (Murnen, Wright, and Kaluzny 2002; Izugbara 2004; Gupta 2000;
Kaler 2003, 2004; Sternberg 2000; Helgeson 1990) have shown that young males make
great efforts to appear invulnerable and invincible in order to prove their merit as men.
They sometimes demonstrate and uphold their invulnerability by displaying bravado,
disregarding physical safety, putting on a guise of being technically infallible, and refusing
to admit to or reveal evidence of failures, mistakes, or lack of knowledge. In the emotional
realm, male youth tend to demonstrate both masculinity and competence by presenting
themselves as emotionally detached, unshakable, and fearless (Burns and Mahalik 2007;
Gupta 2000; Kaler 2003, 2004). As a masculine gender script, the ideology of
invulnerability and emotional control frequently forces young people to avoid and/or
stigmatize procedures that may reveal them to be weak and vulnerable. In the study, there
were also male youth who disclosed that they have not yet sought and may not seek VCT
because it may reveal them to be truly HIV-positive. They admitted that testing positive
would be unbearable to them and concluded that one was better off without going for HIV
testing. Comments indicating that testing positive would make boys ‘begin to live in fear’,
‘lose their confidence’ or ‘begin to think too much’ filled the available narratives,
occurring side by side with disclosures about having been ‘walking badly’: an indication
that their identities as persons who should be confident and stay unruffled in the face of
risk and danger were more valued than the benefits of VCT.
Sex Education 249
Driving home the implication of the ideology of invulnerability and emotional control
for male youth VCT-related attitudes, Malawian FGD participants agreed that the non-
uptake of VCT services among young boys ‘was not because of (the lack of) money or . . . ’,
but because ‘we do no want to . . . fear’. They noted that even when boys know ‘they are
walking badly’ and ‘would benefit from knowing their HIV status’, they would not seek
VCT because of ‘the possibility of testing positive’, which may mean that one will ‘stay
worrying’. The point was also made that ‘Leave the issue of cost; even if you have the
money for the test, for us the problem is that we fear to face bad news’. Similar comments
emerged in the narratives from Uganda, where one rural-based male youth stated that
‘With me if I went for VCT, I would lose weight within two days’; and another believed that
awareness of the existence of VCT services was high among young people but that a major
reason they do not seek VCT was because they would not want to live in fear. Using himself
as an example, he noted: ‘I . . . won’t go to VCT because if I go . . . I might be told that
I have the disease and I stay worrying a lot . . . ’. In the longer narrative, he maintained that it
was better for him to stay without undergoing HIV testing because he would not lose his
confidence, would not worry, and would live longer. There was also a respondent who
noted that ‘some boys do not go there [VCT] because they might . . . be told that they have
HIV, which might make them begin to fear . . . ’. Another respondent suggested that his
concern with VCT was that it made him afraid. As a boy, he admitted he hated things that
made him afraid.
The role of the masculine ideology of invulnerability and emotional control in male
youth narratives surrounding VCT is also evident in the apparent framing of VCT uptake
as a symbol of lack of self-confidence and an acknowledgment of vulnerability by a boy.
Principally due to this, participating male youth mentioned not wanting people to begin to
think that one was infected, was afraid, or was unsure of oneself as key reasons why they
have not and may not seek VCT. In both countries, for instance, several responding male
youth said they would not want to be seen near VCT service sites. It could give people,
especially peers, the impression that one was unsure of himself or afraid; an impression
that reportedly had the potential to tarnish a boy’s reputation of being strong and tough. In
line with this, one Malawian respondent’s key concern over going for HIV testing was
‘what people would think of me if they saw me going for VCT’. In the longer narrative, he
admits that VCT signifies that ‘you do not have the confidence (in) yourself’. The same
interlocutor would (as he said) rather send a friend to the VCT center (and later get
information from him) than go there himself.
The point made by the Malawian boy above for not seeking VCT is very representative
of issues that emerged from narratives collected in Uganda. For example, one Ugandan male
youth admitted that he would rather die with his condition than go for VCT. Declaring his
preference for staying untested rather than knowing he was infected, his responses framed
VCT uptake as a sign of fear, weakness, and lack of confidence. He was not afraid to die and
felt that peers could begin to think of him as a weakling if they knew he went for HIV testing.
For many of these respondents, therefore, there was significant status attached to carrying on
unperturbed, presenting oneself as confident and invulnerable, and, in the context of the
present study, avoiding VCT. In the words of one Ugandan respondent:
Boys are afraid of having HIV tests because even if they tell their friends that they tested
negative, their friends will not believe them. They will think he is lying. They think that if you
decide to go for an HIV test, then you have the virus.
Another participant noted that the main reason why many boys do not go for VCT is the fear
that they will test positive and then lose their friends and respect. Or, as yet another noted:
Sometimes you go to the center where they provide VCT . . . ; it can happen that you meet
others . . . there. So when you test HIV positive, the other ones . . . may go back to tell people
. . . and those people . . . they laugh at you. Then you get depressed because your friends are
laughing at you.
Judging by the arguments of writers such as Burns and Mahalik (2007), Izugbara and Modo
(2007), and Izugbara (2008), the critical importance attached, in the narratives, to
maintaining an image and reputation of being confident and unperturbed and the belief that
VCT uptake could blemish this reputation clearly derive from and illustrate ideologies that
associate a reputation for strength, emotional control, and invulnerability with adequate
manliness. Among others, Courtenay (2000) suggests that, as a result of the gender ideology
of invulnerability and emotional control, men and boys tend to avoid and/or to stigmatize
procedures that negate, or threaten to negate, their reputation as tough, strong, and confident
persons.
The uptake of VCT by Malawian and Ugandan male youth also tends to be constrained
by the gender ideology that associates manliness with sexual conquest and activity. In the
study, male youth associated VCT uptake with an abstinence career, noting that they
would not go for VCT because they may be told to stop sexual activity. In myriad
comments highlighting a shared belief in the centrality of sexual activity to their identity
as males, responding male youth consistently drew attention to the fear of being told to
stop sexual activity as a key reason they would not seek VCT. Scholars (such as Gupta
2000; Kaler 2003, 2004; Sternberg 2000; Izugbara 2007) have suggested that, among boys
and men who subscribe to traditional images of manliness, sexual activity confers a status
of adequate manhood, fuels the sense of manhood, and is considered an essential aspect of
the male nature. Such men and boys also tend to view sexual activity as a natural
accompaniment of being male and to challenge and steer clear of activities that call for
abstinence and sexual inactivity. According to the respondents, young people seeking
VCT services are often advised to stop sexual activity, whether or not they test positive.
Noting that they enjoyed having sex, several male youth reported that they avoided VCT
centers because they did not want to be advised to stop having sex. As one of them noted,
‘ . . . boys see sexual intercourse as a good thing and if we are told that we should not have
sex, we do not feel all that okay’. Another added: ‘The things that make us unhappy with
VCT include that the hospital people . . . advise that if a person is found with HIV, he
should not engage in sexual intercourse again . . . this is what they tell them’. There was
also a Malawian young male who was avoiding VCT because ‘if I go there and find out
that I have HIV, I will never have any chance of having sex with any woman’. Similar
beliefs were widely voiced in Uganda, where it was noted that boys avoided VCT services
because if they tested positive ‘they would lose their girlfriends’, ‘never have the
opportunity to have sex again’, ‘be forced to become abstinent’, and so forth. In the words
of a Ugandan participant: ‘You might go for VCT with your girlfriend and she may
test negative while you test positive. Do you see how you lose her? Yet you love her
very much!’
Participating male youth were also discouraged from seeking VCT services because
the providers were mainly women. They spoke about VCT being a very sensitive service
that they did not feel comfortable obtaining from female providers. One Ugandan male
youth reported that he lived very near to a clinic, Kirokole Council Clinic (KCC), which
offers free VCT service. He admitted that ‘ . . . at the KCC, even if you go there four times
a day (for VCT) they cannot send you away’. However, he would never think of seeking
VCT there because the providers were all women. He says ‘ . . . but the bad thing about the
place (KCC) is that they have many young girls trained as nursing assistants. You find that
Sex Education 251
she is the one to consult . . . me . . . I cannot . . . go before that girl’. Another respondent
noted that he would prefer to be attended to by male service providers so that he could
freely ask them any questions that he may have. Responses like the ones described here are
understandable and further highlight the nuanced effects of gender on the uptake of VCT
among the study participants. The literature dealing with adolescent male health behavior
suggests that young males may find it disempowering to seek reproductive health services
from female providers (Kapphahn, Wilson, and Klein 1999; Sychareun 2004). It is also
argued that men sometimes feel intimidated and humiliated when they rely on women for
help (Burns and Mahalik 2007). For many young males, reliance on female service
providers tends to symbolize submission especially when they have to undergo
uncomfortable or humiliating medical procedures, follow directions, and defer to women

over the decision-making process. For instance, Afangideh, Etuk, and Akpabio (2006)
reported feelings of helplessness, resentment, powerlessness, and discomfort in a sample
of Nigerian male youth receiving reproductive healthcare services from female providers.
Participants also reported that youth were sometimes dissuaded from going for VCT
because they had been having unprotected sex and knew or thought they were already
infected. One Ugandan participant reported that ‘Some boys do not go for VCT because they
have been having sex without condoms and with different girls. They think they already
have the virus and see no need to confirm again’. This point emerged in many FGDs and was
generally upheld by participants, one of whom noted ‘Sometimes when you have been
having fun . . . with different girls you fear to go for VCT . . . Fear due to past lifestyle is
why some young people opt to stay ignorant of their status’. And yet another observed:
‘I think if you have been going out and having unprotected sex, then definitely just know that
you have the virus. So when that is the case, people don’t feel like going to test again’.
In Malawi, this point was also bluntly made by a respondent who observed that ‘Some of us
young people do not also go for VCT because we have been having unprotected sex. We feel
that ah . . . we already have the HIV so why waste money and time to undergo testing’.
The long distance to where VCT services are located was also mentioned as a barrier to
getting tested by male youth, especially those in rural and remote areas. Speaking about
this point, a respondent in a rural Malawian FGD pointed out that to get an HIV test in the
community one has ‘to go all the way to the district hospital which is far away’. Another
also maintained ‘If the . . . testing services were put near here, it would be better than
spending a lot of money on transport’. Ugandan participants acknowledged that
widespread information about VCT services notwithstanding, they (the services) were
usually out of the physical reach of many young people. One of the respondents pointed
out that ‘One major problem is that the places for such services are often very far’. Still in
acknowledgement of distance as a problem, yet another respondent proposed:
I just think that maybe if it can happen that a bus just comes here and it is said that those who
wish to test should board and go to test and come back. In that way maybe we can go and have
our blood tested as we will not spend money on transportation.
A significant number of respondents from both countries specifically mentioned cost as a
barrier to the uptake of VCT services. In Uganda, for instance, comments suggesting that
VCT services were unaffordable to young people filled the narratives, as exemplified in
the following discussion:
Moderator: Have any of you tried to get VCT service?
Participant 1: . . . I haven’t seen it anywhere
Participant 2: Another thing is . . . the money for testing
Moderator: No money for testing?
Participant 2: Yes
Moderator: How much do they charge?
Participant 3: Five hundred shillings
Participant 2: It is two thousand and five hundred shillings.
Some Malawian male youth also reported lacking finances that would enable them to
travel to where VCT services are obtained and/or pay for VCT services. Male youth in
both countries would not ask their parents for money to undergo HIV testing. This would
alert their parents to the fact they were sexually active. Getting money from one’s parents
to undergo HIV testing also obliged young people to show the test result to their parents.
As they wanted parents neither to know they were already sexually active nor to ask them
for their test result, respondents did not consider asking their parents for money to be a
viable solution to their lack of resources to obtain HIV testing.
Widespread information on VCT notwithstanding, some young people reportedly did
not know where VCT services could actually be obtained. Buttressing this point, a
Malawian respondent asserted that ‘another major problem we have here is that many
young people do not even know where they can submit their blood samples . . . ’ His
suggestion was that people need to be made ‘ . . . more aware of where such services are
located or can be found’. In Mkanda, one of the specific sites of the Malawian FGDs, it was
reported that there was a free VCT service involving the submission of blood samples and
their collection a few days later. Participants in the FGD that was held in this community,
however, affirmed that ‘only a few people knew that blood samples can be submitted right
here in Mkanda’. Male youth in both countries emphasized ignorance and illiteracy as key
constraints to seeking HIV testing. These prevented people from knowing where VCT
services could be obtained and also from understanding the purpose and importance of
VCT. This point was underscored thus: ‘For educated people, getting tested is not a
problem because if one finds out that he has the virus then he will be told how to live
longer’. Drawing examples from his community ‘where many out-of school boys were
living’, a respondent maintained that such male youth ‘may not go for HIV testing because
they do not even know . . . [where to find VCT services]’
It is salient here, however, to highlight that several participating males in the study
challenged the view that distance, ignorance, and finance were key barriers to the uptake of
VCT services. They noted that regular and widespread HIV campaigns have made nearly
everybody aware of the importance of VCT and that there were several places, even in
rural areas, where VCT was offered free of charge. For instance, FGD respondents in
Malawi admitted that: ‘It is easy because . . . at MACRO they do not even ask for money.
So it’s up to you to go there for a blood test’. It was also said that ‘like . . . at Zingwangwa;
they have established Banja La Mtsogolo. Even at the markets they do blood tests’. Similar
sentiments were expressed in Uganda, where several respondents reported knowledge of
places where free VCT services are offered, maintaining that the issues that hinder them
and other male peers from seeking VCT had little to do with distance, cost, and ignorance.
VCT – a double-edged sword

To male youth in the study, VCT was both advantageous and risky. It was recognized as likely
to help the HIV-infected live longer, but was partly blamed for the spread of the virus. VCT
was also associated with problems including suicide, loss of motivation in life, and breakdown
in social ties and networks. Overall, the common belief among participating males was that
it was safer not to go for HIV testing. Rather than seek VCT, many reported they preferred
to continue believing that they were uninfected, stay abstinent, or become born-again.
Sex Education 253
The major advantage of VCT identified by the respondents was that it helped people
know their status, preparing them for positive living with or without the virus. FGD
narratives generally associated VCT with healthier lifestyles, with interlocutors agreeing
that it is beneficial both to the infected and uninfected. The most prolific articulation of this
point was in a Malawian FGD, in which it was agreed that:
The good side of undergoing VCT is that it lets you know which side you belong. So you are
aware of whether you are positive or negative. If you are positive you are able to preserve
yourself, because you have knowledge about your body. If you are negative you stand a
chance of preserving yourself too. So VCT is good.
HIV testing was also thought to foster positive change in sexual behavior. It encouraged
infected people to avoid unprotected sex with others and the uninfected to continue
to protect themselves. Driving this point home, a Ugandan participant noted that
‘VCT allows you to live longer if you are infected. The counselors advise you on what to
do and how to live’. Another respondent observed that:
the good thing with VCT is that you know your status – whether you are negative or positive.
If you are positive, it’s good because you are given guidance and counseling on how to live.
If you don’t test you also continue living in fear.
In both countries, VCT could also ‘help infected people to prepare themselves’, and to
‘adequately plan for their children’s schooling’.
Other advantages of VCT identified by male youth in the study include helping
infected people to be linked with providers of ARVs, encouraging the spread of HIV
information to others ‘as infected people may want to educate their wards about HIV’,
building confidence among infected and uninfected persons, preventing further
involvement in risky behavior, and possibly the spread of the virus. VCT was associated
with happiness in the home as ‘people will know their status and work towards living
longer or avoiding being infected’.
On the other hand, VCT was also associated with several negative outcomes. It was
blamed for the spread of HIV, viewed as likely to cause infected people to be de-motivated
about life, and seen as a cause of pain and suffering in many households. In both countries,
respondents admitted that it was common for people who test HIV-positive to deliberately
begin to infect others. The notion of ‘not wanting to die alone’ from HIV resonated clearly
in many of the narratives surrounding the disadvantages of VCT, with a substantial
number of the respondents admitting that they themselves would also infect others should
they test HIV positive. In fact, one respondent’s claim that he would heed the advice of
VCT counselors and not go on to infect others (if he tested HIV-positive) was vehemently
doubted and challenged by other participants, who maintained that he was lying and
merely saying so to impress the interviewers.
Respondents associated HIV with shame. They maintained that the stigma associated
with HIV sometimes encourages people to feel that it is better not to die alone from it.
One Malawian male youth spoke of:
people thinking that others will laugh at them when it is known that they have HIV. So when
they discover they are infected they say instead of suffering the shame alone, I will spread it to
everybody so that we are all in the same situation. That way everybody will be affected.
Ugandan participants also agreed that ‘VCT increases the spread of the disease because if
found positive you might not want to die alone. You spread it further. But without VCT
you might protect yourself’, and that ‘the danger in VCT is that if someone knows he is
infected, he will go to infect others and the virus spreads’. A Malawian respondent also
noted that ‘The major problem I have seen in this area with VCT is that when people test
positive to HIV, they will begin to have unprotected sex with many other people with the
aim that he or she should not die alone’. Several others agreed that the tendency to spread
the virus to others was often common among male and female youth and rich adult men.
Speaking specifically about wealthy men, Malawian participants agreed that:
especially rich men . . . they often forget . . . the advice they receive from the VCT people and
they say when I die I should die with other people as well. They use their money to spread it
. . . paying K5000 (to young girls) just to have sex.
Relatively large numbers of participants claimed first-hand knowledge of persons who
have deliberately infected others after testing HIV-positive.
Testing positive for HIV also reportedly prompted people to give up on life, squander
their wealth, abandon their families, become depressed, and refuse to work and
participate in development activities. Youth from the two countries spoke of people in
their communities who, upon testing positive, not only began to worry about their
impending death, but also refused to participate in development programs. Situations
were reported where infected men and women had refused to contribute to community
development, arguing that ‘they would not be around to enjoy the benefits of those
projects’. Participants also said they knew people who had committed suicide, abandoned
their families, suffered depression, and sold off their properties after testing HIV-positive.
It was noted that:
some people . . . when they go for VCT and test positive, they don’t care anymore about their
families and children. Some will sell their houses and abandon their children to their fate.
They don’t really care about the future of the people they are leaving behind.
One Ugandan participant’s experience was that ‘people who test positive sometimes sell
off their lands and property so that they can use the money to enjoy before dying’. It was
further noted that ‘When such people are asked what their children will eat . . . they say
“My children can eat plantain leaves if they like”’.
An HIV-positive VCT result was also associated with loss of friends, abandonment by
relatives, and exposure to scorn and mortification by community members. Participating
males generally felt that persons infected with HIV died faster when they went for VCT
than when they remained ignorant of their status. One respondent attributed this to the
unhappiness, frustration, sadness, and uncertainty that often followed positive HIV tests
and made ‘ . . . such people think of their impending death’.
Discussions and conclusion

Research conducted in different contexts shows that HIV VCT benefits individuals, families,
communities, and society at large and should be a central component of comprehensive HIV-
prevention strategies. Data on VCT are also essential for planning, budgeting, and improving
HIV/AIDS interventions. The most effective interventions to reduce transmission from
mother to child depend on a woman knowing her HIV status, which in turn depends upon the
availability of information, counseling, and testing services. The effectiveness of VCT in
changing behavior at the individual level has also been demonstrated. In recognition of all
these facts, UNAIDS (2001) has recommended that VCT be mainstreamed within national
HIV/AIDS policies. The importance of VCT notwithstanding, questions about young
people’s experiences, perceptions, meanings, beliefs, and attitudes surrounding it remain
unanswered. Yet, in the view of scholars (such as Ekanem and Gbadegesin 2004; Nyablade
et al. 2001; Zachariah et al. 2003), VCT offers a window of opportunity for snatching young
people from HIV infection and for helping those already infected to live longer and perhaps
Sex Education 255
more fulfilling lives. Following this claim, we investigated VCT-related beliefs and attitudes
among male youth in Uganda and Malawi.
Emerging data indicate that young males in Uganda and Malawi are aware of
mainstream public health discourses on VCT. They were not only very aware of the
existence, nature, purpose, and uses of VCT services, but also knowledgeable about free or
sometimes cheap VCT services offered in their communities. Despite their high-level
awareness of the importance of VCT, the majority of male youth in the study had yet to
undergo VCT, with none of them also demonstrating positive attitudes toward doing so.
Young people’s lack of interest in and apprehension about VCT stemmed from a complex
web of socio-cultural and economic factors, especially a sense of invulnerability, fear
of testing positive, and HIV stigma. Indeed, while data also highlight the physical
inaccessibility of VCT services, lack of adequate information on VCT, provider
characteristics, and economic cost as potential barriers to young peoples’ uptake of VCT,
the bulk of the narratives indicated that the main constraint to the uptake of VCT by male
youth was that it contradicted their sense of self-confidence, strength, toughness,
independence, stoicism, and fearlessness. Many of the narratives framed going for VCT in
terms of danger, lack of self-confidence, and as an acknowledgment of vulnerability, a
tendency rooted in young males’ inclination to perform their masculine identities by
presenting themselves as emotionally detached, unshakable, and fearless about situations.
Participating young men associated VCT with both advantages and disadvantages. They
agreed that VCT could be useful to both the infected and uninfected. It could help the former
live longer and the latter stay uninfected. However, participants also frequently blamed
VCT for the spread of HIV. They noted that it was common for people who test HIV-positive
to deliberately spread the disease to others. The idea of ‘not wanting to die alone’ from HIV
featured prominently in the narratives, with a substantial number of the respondents
stressing that they, themselves, would also deliberately infect others should they test
positive. VCT also reportedly forced people to give up on life, kill themselves, squander
their wealth, abandon their families, and refuse to work or participate in development
activities. Testing positive was associated with loss of friends, abandonment by relatives,
and rejection by community members. Persons infected with HIV also reportedly died faster
when they went for VCT than when they remained ignorant of their status.
The findings of this study raise a number of important issues generally for HIV-related
research, and specifically for VCT promotion. For instance, emerging from the current
study is evidence that while current campaigns and efforts may have succeeded in
popularizing VCT services, their accessibility and sensitivity remain problematic. VCT
services were not only sometimes financially and spatially unfriendly to young people, but
were also socially and culturally unavailable to them. The socio-cultural inaccessibility
and unavailability of VCT to young males is, perhaps, the key reason for their
apprehension over it: VCT negates and contradicts their gender identity as invulnerable
males. Indeed, participating male youth frequently pointed out that taking up VCT would
give the impression that they were infected, were afraid, and/or were unsure of themselves.
Their non-uptake of and negative disposition towards VCT followed largely from their
need to sustain images of self-certitude, imperviousness, and invincibility.
Altering the content of VCT promotion campaigns and services to make them more
sensitive appears to be an urgent need and may also hold the key to encouraging
acceptance of VCT among young males. There is also need for HIV education programs to
engage more deeply with the misconceptions circulating about HIV/AIDS and VCT
among young people. As the study makes evident, a number of questionable beliefs,
including that it is better to live with HIV without knowing it, that many people get
infected while uptaking VCT, and that it is better to keep one’s status secret, still appear to
circulate widely among young people. Evidence of the stigma associated with HIV also
looms large in the narratives, with many of the young men admitting that they themselves
would either commit suicide if they tested positive or go on to spread the virus to others.
With regards to HIV/AIDS-related research, a key message from the current study is the
need for more studies addressing the intersections of gender identities not only with sexual
behavior but also with the way men and women receive and relate to HIV programs and
services, such as condom and ART provision.
The findings from the study also suggest the urgent need for HIV education and mass
media programs to target dangerous subjectivities circulating among male youth. Among
other authoritative sources, Shefer and Foster (2001) have pointed to the capacity of
the school and other educational contexts to open up spaces for the development and
articulation of alternative learning on gender and sexual subjectivities among young people.
They raise the possibility of a large-scale restructuring of male and female subjectivities
via formal and informal educational programs. The goal of such efforts would include
making adequate sexuality information accessible to adolescents as well as deconstructing
inaccurate, even dangerous, narratives of VCT circulating among them. For instance, it will
be important for young males benefiting from such HIV educational programs to learn and
become aware of how deep-rooted but dangerous male subjectivities underlie their attitudes
toward health services and programs, constrain their health and well-being, and ultimately
put them at risk for HIV infection. In conclusion, we suggest a need for comprehensive HIV
education involving both adequate information on HIV/AIDS and engagement with the
range of critical sensitivities – gender, generational, cultural, social, and so forth – which
affect people’s responses to HIV services and programs. This approach to HIV education
and communication is key not only to disrupting the dangerous and unscientific beliefs that
still circulate about HIV/AIDS, but also to freeing young people from the shackles of fear
and consternation over VCT and HIV.
Acknowledgements
Data for this study came from Protecting the Next Generation: Understanding HIV Risk Among
Youth, a project designed by The Guttmacher Institute (USA) in collaboration with the University of
Cape Coast (Ghana), Institut Supérieur des Sciences de la Population (Burkina Faso), Makerere
Institute of Social Research (Uganda), Centre for Social Research (Malawi) and the African
Population and Health Research Center (Kenya). Funding for this project was provided by The Bill
& Melinda Gates Foundation, the Rockefeller Foundation and the National Institute of Child Health
and Human Development (Grant 5 R24 HD043610).
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This article was downloaded by: [Istanbul Universitesi Kutuphane ve Dok]

On: 21 December 2014, At: 01:11

Sex Education: Sexuality, Society and

Male youth and Voluntary Counseling

To link to this article: http://dx.doi.org/10.1080/14681810903059078

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Male youth and Voluntary Counseling and HIV-Testing:

There is limited research addressing the beliefs of adolescents related to Voluntary

*Corresponding author. Email: coizugbara@yahoo.com; cizugbara@aphrc.org

ISSN 1468-1811 print/ISSN 1472-0825 online

studies highlight the importance of engaging the prescriptive images of a target

global health sustainability – most currently typified by the UN Millennium Development

Young people and VCT: constraints and acceptability

uncomfortable or humiliating medical procedures, follow directions, and defer to women

VCT – a double-edged sword

Discussions and conclusion

health considerations. JAMA 58: 1757 –62.

Uganda HIV/AIDS Commission. 2007. HIV/AIDS in Uganda. www.aidsuganda.org (accessed July 3,

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