Targeting heterosexual men in HIV prevention interventions

Seth M. Noar, PhD
Department of Communication, University of Kentucky

Although heterosexual men have not traditionally been targeted in HIV/AIDS prevention efforts, there are some data on factors that uniquely influence heterosexual men’s safer sexual behaviors. For example, studies suggest that traditional male gender roles often operate in a manner that works against safer sexual practices (e.g., Noar & Morokoff, 2002; Pleck, Sonenstein, & Ku, 1993; Seal & Ehrhardt, 2004). Rather than fostering sexual protective beliefs, traditional male gender roles emphasize sexual risk-taking and a sexual double standard. Males with more traditional gender role orientations are more likely to have first sex at an earlier age, more sexual partners in their lifetime, and more negative attitudes about safer sexual practices.

Behavioral interventions for heterosexual men should address gender roles in a way that seeks to challenge some of the tenets of traditional roles and reframe them in a more positive manner. It may be helpful, for example, to appeal to men’s sense of wanting to protect their female partners from harm/disease. Discussions about the ways in which gender roles affect sexual decision-making and about the changing nature of gender roles are central to successful interventions with heterosexual men.

Attitudes about condoms

Study after study reveals that men (including both heterosexual and gay men) report more sexual partners and more negative attitudes about condoms than do women (e.g., Sheeran, Abraham, & Orbell, 1999). These findings converge around a common theme: Men have strong desires for sex and are willing to take risks to enjoy the pleasures of sex. Given that male condom use is widely perceived by men as reducing sexual pleasure, it is hardly surprising that many men use condoms inconsistently or do not wear them at all. A better understanding of how to “pitch” condom use to men is needed. For instance, promotion of eroticization of condom use within sexual encounters has been found to be effective when incorporated into interventions (Scott-Sheldon & Johnson, 2006). Encouraging men to find ways to incorporate condom use into sexual interactions without “ruining the moment” may be particularly important, as this is often cited as a reason for nonuse. Also, a better understanding of the positive aspects of using condoms may be useful (e.g., condoms help some men “last longer”).

In addition, a seemingly obvious aspect of condoms — the many different sizes and types — is often overlooked in the HIV prevention literature. Indeed, studies have revealed that men report different experiences with different kinds of condoms (i.e., condoms that are different sizes, shapes and types), and some data (as well as common sense) tell us that greater comfort on the part of the male (and female) may lead to increased use of condoms (Crosby, Graham, Yarber, & Sanders, 2004). One study found that African American men had a strong preference for the “Magnum” — a larger fit condom that comes in a gold package (Crosby et al., 2004). That same study revealed that men often have clear intentions to use condoms but do not follow through because condom use proved to be problematic (e.g., the condom was too tight, was dried out, etc.). It is important to expose men to different kinds of condoms and lubricants so they can identify the types of products that work best for them.

Communication — or not?

Much of the literature finds that communication with sexual partners about condom use is strongly related to the use of condoms (Noar & Edgar, 2008). What is often overlooked, however, is that this communication can be nonverbal as well as verbal. The few studies that have looked at the sequencing of safer sex communication within sexual encounters suggest that such communication does not take place until just before intercourse is about to begin (Noar & Edgar, 2008). This is likely not the time for a detailed conversation about sexual risk. Rather, communication about condoms at this stage may be as simple as one partner taking out a condom and nonverbally receiving permission from the other partner to use it (Noar, Morokoff, & Harlow, 2002).

Some research suggests that heterosexual men prefer a nonverbal style of communication about condom use, whereas women are more likely to use overt, verbal negotiation strategies (De Bro, Campbell, & Peplau, 1994; Noar et al., 2002). Interventions should emphasize that overt verbal communication is a healthy part of safer sex but is not absolutely necessary for condom use. What is important is that men are assertive about condom use, but such assertiveness can be nonverbal as well as verbal (Noar & Morokoff, 2002).

Race and culture

Interventions directed toward heterosexual men need to be cognizant of differences in cultural norms. Cultural issues that have particular relevance to HIV prevention for heterosexual men include differences related to preferences for particular sex acts (e.g., engagement in anal sex), mistrust of the medical system, religiosity, conceptions of masculinity, and conceptions of relationship power (Resnicow, DiIorio, & Davis, 2008). Meta-analytic studies suggest that HIV-prevention interventions in which facilitators and participants are matched in terms of race are more effective than interventions in which matching did not occur (Noar, 2008). Simply put, interventions advocating changes that are consistent with the cultural beliefs of members of the target audience are more likely to be successful than those that advocate changes that are inconsistent with cultural beliefs and norms.

Conclusion

Although heterosexual men have largely been a “forgotten group” in HIV prevention (Bowleg, 2004; Exner, Gardos, Seal, & Ehrhardt, 1999), trends in the epidemic are such that this group can no longer be ignored. Heterosexual men’s role in the epidemic must be more clearly understood and the development of interventions targeting them given a higher priority. Only by targeting and tailoring interventions to men’s unique needs, experiences, and preferences will such efforts be effective in changing their behavior and ultimately averting new HIV infections.

References

Bowleg, L. (2004). Love, sex, and masculinity in sociocultural context: HIV concerns and condom use among African American men in heterosexual relationships. Men and Masculinities, 7, 166–186. doi:10.1177/1097184X03257523

Crosby, R. A., Graham, C. A., Yarber, W. L., & Sanders, S. A. (2004). If the condom fits, wear it: A qualitative study of young African-American men. Sexually Transmitted Infections, 80, 306–309. doi:10.1136/sti.2003.008227

De Bro, S. C., Campbell, S. M., & Peplau, L. A. (1994). Influencing a partner to use a condom: A college student perspective. Psychology of Women Quarterly, 18,165–182. doi:10.1111/j.1471-6402.1994.tb00449.x

Exner, T. M., Gardos, P. S., Seal, D. W., & Ehrhardt, A. A. (1999). HIV sexual risk reduction interventions with heterosexual men: The forgotten group. AIDS and Behavior, 3, 347–358. doi:10.1023/A:1025493503255

Noar, S. M. (2008). Behavioral interventions to reduce HIV-related sexual risk behavior: Review and synthesis of meta-analytic evidence. AIDS and Behavior, 12, 335–353.

Noar, S. M., & Edgar, T. (2008). The role of partner communication in safer sexual behavior: A theoretical and empirical review. In T. Edgar, S. M. Noar, & V. Freimuth (Eds.), Communication perspectives on HIV/AIDS for the 21st century (pp. 3–28). New York, NY: Erlbaum.

Noar, S. M., & Morokoff, P. J. (2002). The relationship between masculinity ideology, condom attitudes, and condom use stage of change: A structural equation modeling approach. International Journal of Men’s Health, 1, 43–58. doi:10.3149/jmh.0101.43

Noar, S. M., Morokoff, P. J., & Harlow, L. L. (2002). Condom negotiation in heterosexually active men and women: Development and validation of a condom influence strategy questionnaire. Psychology and Health, 17, 711–735. doi: 10.1080/0887044021000030580

Pleck, J. H., Sonenstein, F. L., & Ku, L. C. (1993). Masculinity ideology: Its impact on adolescent males’ heterosexual relationships. Journal of Social Issues, 49(3), 11–29. doi:10.1111/j.1540-4560.1993.tb01166.x

Resnicow, K., DiIorio, C. K., & Davis, R. (2008). Culture and the development of HIV prevention and treatment programs. In T. Edgar, S. M. Noar, & V. Freimuth (Eds.), Communication perspectives on HIV/AIDS for the 21st century (pp. 193–220). New York, NY: Erlbaum.

Scott-Sheldon, L. A. J., & Johnson, B. T. (2006). Eroticizing creates safer sex: A research synthesis. Journal of Primary Prevention, 27, 619–640. doi:10.1007/s10935-006-0059-3

Seal, D. W., & Ehrhardt, A. A. (2004). HIV-prevention-related sexual health promotion for heterosexual men in the United States: Pitfalls and recommendations. Archives of Sexual Behavior, 33, 211–222. doi:10.1023/B:ASEB.0000026621.21559.cf

Sheeran, P., Abraham, C., & Orbell, S. (1999). Psychosocial correlates of heterosexual condom use: A meta-analysis. Psychological Bulletin, 125, 90–132. doi:10.1037/0033-2909.125.1.90