Fostering a healthy public for men and HIV: a case study of the Movement for Change and Social Justice (MCSJ)

The paper addresses how to foster a healthy public to tackle the persistent challenge of men’s poorer outcomes across the HIV prevention and treatment cascade. Despite long-standing evidence that men fare worse than women in HIV testing, initiation, and viral suppression, recent global attention (e.g., UNAIDS Blind Spot report and MenStar Coalition) has created an opportunity to mobilize coordinated responses. The authors ask how to frame the problem of men and HIV in ways consistent with feminist and human rights principles, avoid individual-blame narratives, and engage researchers, community actors, health services, and political stakeholders effectively. Focusing at the local scale, the paper examines Gugulethu, Cape Town, using the emergence and activities of the Movement for Change and Social Justice (MCSJ) to explore approaches to building inclusive, informed, and impactful public engagement around men and HIV.

The paper situates the men-and-HIV problem within a growing literature documenting men’s poorer outcomes along the HIV cascade and identifying multi-level drivers, including masculine norms, labor and economic structures, and service design barriers. It references prior advocacy and scholarship calling attention to men in HIV programs and the recent policy momentum (e.g., UNAIDS 2017 Blind Spot; MenStar Coalition). The authors also draw on conceptual work on ‘healthy publics’ (Hinchliffe et al., 2018) and South African histories of AIDS activism, highlighting how knowledge production, political mobilization, and community engagement intersect to shape public health practice.

Design: Qualitative case study of MCSJ linked to the iALARM research project (a 5-year NIH-funded initiative at the University of Cape Town in partnership with Brown University) in Gugulethu, Cape Town. The study synthesizes multiple data sources: participant observation; qualitative and quantitative process evaluations of the iALARM Task Team and MCSJ; reflections from the UCT-based research team; and several Masters-level sub-studies. Ethical approval: UCT Faculty of Health Sciences Human Research Ethics Committee (#802/2014); informed consent obtained. Setting and intervention context: Gugulethu (~100,000 residents) and the Klipfontein health sub-district. iALARM initially focused on aligning services between NY3 Clinic and Sonke Gender Justice’s Men’s Wellness Centre by convening a ‘Linkage and Retention in Care Task Team’ (iALARM Task Team) comprising clinic and NGO staff. Scope expanded to include broader community stakeholders (multiple NGOs, community structures, and sub-district officials). Core approach: The intervention was the convening itself—regular Task Team meetings primed with locally relevant health information on men and HIV to catalyze identification of service gaps and coordinated responses, without prescribing a specific biomedical or behavioral intervention. Data and activities informing the case: Retrospective cohort analysis of the HIV treatment cascade by gender in the sub-district; formative qualitative research on local barriers for men; ongoing process evaluations of information use; documentation of MCSJ campaigns; and analysis of enabling conditions, balancing acts, and strategies. Staff recruitment emphasized deep local knowledge and activist experience (notably community engagement coordination by Mandla Majola). Analytic focus: The paper synthesizes lessons learned into three domains—enabling conditions, balancing acts, and strategies—illustrated with concrete campaign cases (e.g., pharmacy staffing, dental services, ER triage).

- MCSJ emergence and model: Originated from a locally catalyzed response to pharmacy access failures, evolving into a networked, non-partisan health and social justice movement rooted in Gugulethu. Operates through time-limited ‘campaigns’ that gather evidence, engage stakeholders, and advocate for solutions. - Concrete outcomes: Secured an additional pharmacist at the local day hospital; prompted the City to add capacity to NY3 dental services after community-led audits and testimonies documented unmet need; improved community understanding of ER triage and strengthened state–community trust through brokered dialogues; organized campaigns on ARV stock issues, condom distribution in schools, ER safety, school safety, and GBV. - Men and HIV focus: Through the MCSJ Men’s Forum, coordinated dialogues on men’s health, GBV forums, leadership and gender-transformative trainings, support for men’s ART adherence clubs, a Men’s Health Summit, and engagement with local football clubs. Disseminated iALARM findings via a city-wide NGO networking event, Annual Research Indabas, street committee outreach, and representation at the 2019 International AIDS Conference Men & HIV Forum. - Enabling conditions: Flexible, light-burden funding (from iALARM/UCT, Acacia Global, private donors) enabling rapid, low-infrastructure action; experienced activist leadership with deep local networks and political acumen; deliberate cross-hierarchical and cross-sector convening; and strategic mobilization of multiple knowledge forms (academic epidemiology and qualitative findings, community-generated audits and testimonies). - Balancing acts: Managed tensions around scope (responsive local needs vs. a men-and-HIV thread), geography (rooting in Gugulethu vs. expansion), roles (advocacy/oversight vs. service delivery contracts), identities (activist vs. academic; community vs. state), NGO-isation pressures (siloed programs, narrow indicators, short cycles), and gender approach (gender-sensitive supports vs. gender-transformative change). - Strategies: Inclusive convening that avoids siloed subgroup identities, framing diverse concerns within a broader political-economic narrative; leveraging academic partnerships and evidence for legitimacy and influence; cultivating allies within state services while holding institutions accountable; institutionalizing research engagement cycles (Annual Research Indabas; continued Task Team meetings) and linking postgraduate research to community-identified needs. - Perceived impact and demand: MCSJ is widely viewed locally as effective and trusted, with requests for expansion and partnerships, reflecting unmet needs and a vacuum in community-based leadership amid declining HIV funding and politicized environments.

The findings demonstrate that fostering a healthy public for men and HIV requires more than implementing predefined interventions. Sustained, inclusive convening across community and health system boundaries, coupled with mobilization of accessible, locally salient information, can catalyze coordinated action and pragmatic service improvements. MCSJ’s campaigns show how evidence (both academic and community-generated) and activist tactics, tempered by collaborative engagement with frontline state actors, can yield tangible gains (e.g., added pharmacy and dental capacity) and build mutual understanding (e.g., ER triage). By threading a focus on men and HIV through broader, community-responsive agendas, MCSJ avoids backlash and aligns with feminist and rights-based principles, addressing structural and normative drivers without blaming individuals. The approach underscores the value of flexible funding, embedded leadership, and iterative research–practice cycles. Collectively, these elements illustrate a locally grounded, replicable model for developing healthy publics that can be adapted to other contexts facing men’s inequities in HIV care.

In a short period and with modest resources, MCSJ has contributed to building a healthy public around men and HIV and broader health and social issues in Gugulethu. Its locally rooted, campaign-based, evidence-informed, and inclusive approach departs from conventional public health models that cast communities as passive recipients and from narrowly defined activist identities. Prioritizing “one small thing at a time” at local scale has enabled closer, sustained collaboration among residents, activists, academics, and service providers. However, the model remains fragile, dependent on flexible funding and a small cadre of experienced leaders. The authors and MCSJ aim to continue Annual Research Indabas and Task Team meetings, and to leverage growing global attention to men and HIV to support ongoing research and activism. Future work will develop theory-generating case studies on strategies to mobilize individuals, services, and communities for durable healthy publics, complementing evidence on what works with how, for whom, and for how long it works.

- Funding fragility: Dependence on short-term, flexible funds (e.g., iALARM ending in 2020) and uncertain long-term financing constrain sustainability and scale. - Leadership dependence: Heavy reliance on a small group with specialized activist skills and deep local networks limits rapid capacity transfer and resilience. - Scope and role tensions: Ongoing ambiguity around geographic expansion, thematic focus (men and HIV vs. broader needs), and boundaries between advocacy and service delivery risks mission drift or co-optation. - NGO-isation context: Fragmented civil society with siloed programs, competitive funding, narrow indicators, heavy reporting, and short cycles challenges cross-sector cooperation and long-term solutions. - Generalizability: As a locally specific case study based on qualitative synthesis and participant observation, findings may not directly generalize without adaptation to other socio-political contexts.