While new HIV cases are declining, young women aged 24 and under are three times more likely to contract the disease.
Mahlanya, Swaziland – The 300 or so pictures of “the ideal man” drawn by boys joining a male-mentoring charity in Swaziland are almost always the same. They depict a solitary and solemn figure who appears domineering – on his land, drinking and wearing traditional dress.
“I thought a man was somebody who’s got a family, somebody who’s got authority, power, that kind of thing,” says Lungelo Fakudze, one of the roughly 100,000 orphans in Swaziland, which is home to 1.3 million people.
It is a difficult image to break in Africa’s last absolute monarchy, ruled by King Mswati III – who has 15 wives and can pick a new one yearly from thousands of virgins presented to him during an annual ceremony – and which is blighted by the world’s highest rates of HIV, TB and intimate partner violence.
The scourge of HIV/Aids during the 1990s and 2000s means that half of the population of Swaziland are children and almost a third of adults have HIV. But a strong notion of male pride and a sense of duty to provide for others, means many men conceal their HIV status and continue to work even when unwell.
The men also stay away from health clinics, which tend to be female-centred, where they could get a diagnosis and treatment. As a result, while more women contract HIV, more men die as a result of it.
“They believe that they should be big and strong and solitary and authoritative. Reasons you’re less likely to go to the clinic and get a check-up and seek out medical services until it’s too late,” says Tom Churchyard, the director of the charity Kwakha Indvodza (KI), which means Building a Man.
As more men die, the shortfall in male role models grows. KI is trying to fill that void by taking boys, mostly orphaned by Aids, and deconstructing their dangerous notions of what it means to be a man.
“I’ve seen so many people out there, they take this thing of being a man – using it the wrong way – taking it and abusing other people,” says Fakudze, who started coming to KI’s Mahlanya youth centre three years ago when he was 15.
High rates of unemployment, about 40 percent, in Swaziland also present a challenge to the image of the ideal Swazi male. This has pushed some men over the border to work in South Africa’s mines and others towards alcoholism or other forms of abuse.
“You find that you’re unable to protect, you’re unable to provide, so that’s maybe where the violence comes in, because you’re trying to prove something,” says Emmanuel Mkhwanazi, a KI counsellor.
One in three girls surveyed by UNICEF reported some form of sexual violence during childhood.
Mswati is often accused of reinforcing a patriarchy that oppresses women and keeps them chasing after “blessers” – older men who exchange gifts, school fees or other forms of payment for sex. The fact that the highest rates of HIV are among young women – more than one in 10 females aged 15-24 are living with HIV – and men some 10 years their senior suggests this “blesser” culture may be exacerbating the spread of the virus.
HIV is often diagnosed in women during pregnancy, with those who test positive being put on antiretroviral (ARV) drugs, which drastically reduce the chance of transmission to their babies, as well as future partners, and prolong their lives.
But diagnosing men, who usually avoid clinics, remains a challenge.
“We always sit and wonder, where are the men?” says Dr Nduduzo Dube. Two-thirds of the patients he treats at the Aids Healthcare Foundation clinic in Manzini city are women.
“Swaziland is a very traditional, masculine-based society so they think they should support a whole family,” says Yen-Hao Chu, who is part of a Chinese medical mission working in Swaziland.
Men earning around $15 a month “won’t want to face any other problem other than work” or become “permanently controlled” by clinics which cut into precious working hours, Chu says.
The medical response to HIV was “feminised” to tackle soaring female prevalence, Dube explains, but he thinks this approach now needs to evolve.
“We’ve tried to engage into programmes where we try and encourage men to test, which basically involves going to their workplaces or … places where they gather as a group.”
Clinics in “kombis”, small minibuses that travel through the streets, serve the most hidden groups, such as homosexual men.
Researcher Bekhie Sithole believes that men’s withdrawal from healthcare is a result of the “moralising” of HIV and the way that men have been painted as the perpetrators and women as their victims.
“Men have developed their own attitude to that, saying, ‘We are the bad guys, so we will do things the way we like’,” he says.
Dube explains that in such a patriarchal society, “where men are put up there”, they are not inclined to accept being “blamed for anything”.
Most men ignore local clinics that are aimed at, staffed by and used by women, and opt instead to visit a local inyanga, or witch-doctor.
They offer queue-free, man-to-man private consultations and, sometimes, the promise of what the patient wants to hear – either that they don’t have HIV or that it can be “cured”.
“Part of the appeal of witch-doctors is that they are offering cures, not treatment that require you to come back for check-ups,” says Chu.
Newspaper adverts from witch-doctors promise to “bring back lost lovers or separate them within a day”, resolve “problems at work even if they want to fire you”, attract “white or rich people” and allow “control of your husband or wife using a remote” as if by magic.
But the “medicines” prescribed can be brutal.
“They will look for the most awkward thing for you to do, just like sometimes they will tell you have to kill your brother … so if you don’t do it they can say, ‘well you can’t get better because you didn’t do it’,” says Dube.
One HIV “cure” is to have sex with a virgin.
“People don’t say it openly now because they know it’s wrong, but it’s still prescribed by traditional healers and they still do it,” said a foreign doctor who could not speak on the record.
Great strides have been taken to bring medics and witch-doctors together to carve out roles – healers will treat HIV-related ailments but recognise the virus and refer patients for testing and treatment.
“We see that some of them have seen the benefits of ARVs so in their concoctions they do try and put ARVs, so they can keep their clients, because there is monetary benefit in that,” says Dube.
From January 2017, Swaziland will start putting anyone who tests positive – regardless of their viral load – on ARVs for life, to prevent the virus from being spread early on.
Trials by medical charity Doctors Without Borders (MSF) found that this approach appeals to Swazi men as it means that they will stay stronger for longer.
“I think this is also about keeping the balance of being a man in your community. You can live your own life, you can make your own decisions, without the need of being dependent on somebody else,” says Bernhard Kerschberger, from MSF Swaziland.
Getting children to take pills for life is more difficult. Boys fear being seen taking daily ARVs because “they may be stigmatised,” says Fakudze.
Campaigns calling for circumcision, which may reduce the risk of heterosexually acquired infection in men by approximately 60 percent, mostly fall on deaf ears as boys and men cite concerns over religion, virility and their warrior status.
A 19th century Swazi king banned circumcision after blaming his failure to find enough warriors to go to battle on the number of men recovering from the operation.
King Mswati has asked his countrymen to get circumcised, although it is unclear whether he has done so himself.
Most of the boys that pass through Kwakha Indvodza get circumcised, either after learning about it at holiday camps or on accompanied clinic visits.
With more openness about HIV – even if school sex education still preaches abstinence and fidelity – and better treatment models, the number of Swaziland’s lost boys should decline.
Fakudze described sleepwalking through life alone before he found “a family” in the KI brotherhood.
“Now I have goals, my own goals, I’ve got a vision of my life. I’ve got a future, somewhere,” he says.
That doesn’t involve getting HIV, making his children suffer as he did, or being the man he once drew.
“I want to be the man who is caring, who is responsible, who cares for the family, the people living with him, the environment and even care about my health too. A man who will have dignity, honour and respect, just like that.”
Hannah McNeish reported from Swaziland with the help of the International Reporting Project (IRP) .