Medical Anthropology Cross-Cultural Studies in Health and Illness

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Blaming Machismo: How the Social Imaginary is Failing Men with HIV in Santa Cruz, Bolivia Carina Heckert To cite this article: Carina Heckert (2016): Blaming Machismo: How the Social Imaginary is Failing Men with HIV in Santa Cruz, Bolivia, Medical Anthropology, DOI: 10.1080/01459740.2016.1142989 To link to this article: http://dx.doi.org/10.1080/01459740.2016.1142989

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MEDICAL ANTHROPOLOGY http://dx.doi.org/10.1080/01459740.2016.1142989

Blaming Machismo: How the Social Imaginary is Failing Men with HIV in Santa Cruz, Bolivia Carina Heckert

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Department of Sociology and Anthropology, University of Texas at El Paso, El Paso, Texas, USA ABSTRACT

KEYWORDS

Drawing from an ethnography of HIV care in Santa Cruz, Bolivia, in this article I explore how the social imaginary surrounding gender relations shapes men’s experiences of seeking care for and living with HIV. Popular understandings of gender relations, which draw heavily on the machismo concept, intersect with a global health master narrative that frames women as victims in the AIDS epidemic in a way that generates a strong sentiment of blaming machismo within local HIV/AIDS-related services. Statements such as, “it’s because of machismo” are used to explain away epidemiological trends. Participant observation in the context of HIV care, coupled with illness narrative interviews, illuminate how blaming machismo shapes men’s experiences of care and the ways that they feel excluded from various forms of support. Thus, the illness experiences of men with HIV problematize the machismo concept and how it is drawn upon in the context of care.

Bolivia; global health; HIV/ AIDS; masculinity; politics of life

“It’s because of machismo,” Dr. Sandoval, a doctor with the government-operated HIV clinic in Santa Cruz, Bolivia, explained as I commented on the increase in new cases of HIV among women in Bolivia over the past decade. Her response echoed sentiments expressed to me by other male and female doctors, public health officials, health care workers, and even HIV activists and people living with HIV/AIDS (PLWHA) who I had interviewed. Such a discourse, which blames machismo for HIV, circulates in the media and among the public in discussions surrounding HIV. Public health brochures aimed at testing and preventing HIV even list machismo as a risk factor. Given the stark manifestations of gender inequalities in Bolivia, including high rates of violence against women (Bott et al. 2013), blaming machismo intuitively makes sense. Yet, what does such a discourse imply for men with HIV? And what does it mean to call machismo a risk factor? While machismo typically refers to gender relations in Latin America, the way individuals evoke the term in relation to HIV in Bolivia goes beyond the local context. Understandings of HIV in relation to machismo emerge at the intersections of local understandings of gender relations and a global health master narrative that claims to prioritize women in relation to the HIV epidemic, while inadvertently generating a ‘victim’ and ‘victimizer’ dichotomy, framing men as transmitters of HIV. While a focus on women as a part of global health responses to HIV has been a welcome turn following decades of insufficient attention toward women, it is important to consider the ways that men and women are being portrayed and what these portrayals imply in terms of individual experiences. Several scholars (e.g., Richey 2011; Seckinelgin 2011; Chong and Kvasny 2007) critiqued the stereotypical ways that global health interventions frame gender and sexuality, noting that these stereotypes limit the effectiveness of interventions. Thus, a blaming machismo discourse reflects one way in which global HIV interventions are unfolding locally.

CONTACT Carina Heckert [email protected] El Paso, Old Main Building, El Paso, TX 79968, USA. © 2016 Taylor & Francis

Department of Sociology and Anthropology, The University of Texas at

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In this article, I interrogate the ways that a blaming machismo discourse has become a part of local understandings of HIV and what such a discourse implies for men with HIV. To do so, I first explore the machismo concept, moving into a theoretical discussion of how blaming machismo represents a gendered politics of life that generates compassion for some PLWHA and disdain for others. I then discuss how such a discourse intersects with global health messages in the realm of HIV care to shape men’s experiences of seeking care. I draw on the life histories of four men—José Carlos, Rafael, Efraín, and Aldo—to show different ways that masculinities exist and how the popular imaginary of masculinity shapes risk, decisions and experiences surrounding seeking care, and experiences of living with HIV. In the process, I interrogate the ways their life histories embody various forms of masculinity, problematizing the use of machismo in relation to understanding HIV. I end with a discussion of what these illness narratives imply in terms of HIV interventions.

The ethnographic context Located in the tropical eastern lowland region of Bolivia, with nearly two million people, Santa Cruz is Bolivia’s largest city and one of the fastest growing cities in the world. At first glance, Bolivia is not the most logical place to research HIV. Infection rates are low (0.15%, Centro Departamental de Vigilancia y Referencia 2013) compared with other countries.1 A Bolivian law guarantees access to life-saving antiretrovirals (ARVs), and government-run clinics distribute the drugs for free using grants from the Global Fund to Fight AIDS, Tuberculosis, and Malaria (“the Global Fund”). With ARVs as the most effective form of prevention, often suppressing viral loads to the point that the virus is undetectable, hypothetically, ARV access and retention in care can contain the epidemic. However, the Bolivian Ministry of Health estimates that only 35% of those with an HIV diagnosis are in care (Medrano Llano 2014), giving Bolivia the lowest ARV coverage rate in Latin America (Pan American Health Organization 2012). Recent epidemiological trends are also significant. Since 2005, registered cases of HIV have increased rapidly. In 2005, the Ministry of Health registered only 330 new cases of HIV nationwide. By 2009, the Ministry was registering more than 1000 new cases per year in Santa Cruz, which is home to more than half of all cases in Bolivia (CDVIR 2013). During this same period, the gendered nature of the epidemic began to shift. Between 1984 and 2005, nearly 80% of registered HIV cases were in men, the majority men who have sex with men (Wright 2000, 2006; RedVihda 2005). By 2009, 43% of new cases were women (CDVIR 2010), marking a trend that has continued to the present day (CDVIR 2013). Bolivia is highly dependent on external resources to maintain funding for HIV programs. It is the only country in South America and one of two countries in Latin America with such a classification; more than 75% of funding for HIV interventions originates from the Global Fund (Pan American Health Organization 2012). Further, throughout my fieldwork that spanned August 2013 to August 2014, Bolivia was in the midst of an AIDS funding crisis as the national government began expelling key development agencies; at one point, the Global Fund froze Bolivia’s grants when the Ministry of Health violated the terms of the grant agreement. Thus, I conducted my fieldwork during a moment in time characterized by financial insecurity for HIV programs. At odds with the national government, civil society organizations, HIV activist groups, and local public health bodies felt a heightened need to play to donor priorities in an effort to regain and maintain HIV funding.

Defining machismo The machismo concept has a problematic history within the anthropological literature on Latin American men. Lewis (1961), Stevens (1965), and Gilmore (1990) popularized the use of the term in academia, but often presented essentialized understandings of what it meant to be a man. While Gilmore noted positive traits associated with machismo, such as chivalry and bravery, the focus has often been negative. What Stevens (1965:848) called the “cult of virility”—wife beating, infidelity,

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drinking too much, and abandoning children—became associated with machismo, contributing to the stereotyping of Latin American men. Recent literature on masculinity offers a necessary critique of this work and complicates understandings of Latin American men (e.g., Brandes 2002; Gutmann 1996; Olavarría 2001). Gutmann (1996, 2003, 2007) has brought attention to the diversity of masculinities that coexist, referring to machismo as simply one option that individuals draw on to guide their behavior. Critical of the rampant use of the machismo concept, he has pointed out that reliance on this term is more problematic than useful, because it ignores the variety of ways that men construct their masculinities. Further, he has pointed out that machismo is a relatively recent invention and lacks the historical force claimed by many scholars (Gutmann 1996). More recently, Wentzell (2013) has illuminated the ways that men construct their masculinity differently throughout their life course. The Mexican men in Wentzell’s research drew on various options for understanding their masculinities, framing their own sense of manhood in a way that made sense in light of life experiences. Lancaster’s (1994) research on gender relations in Nicaragua earlier highlighted how social class shaped men’s behaviors, and Ferrándiz’s (2003) research on poor, urban men in Venezuela drew attention to how poor men are labeled as pathological by society as a whole, creating ‘wounded’ masculinities. Thus, social class is among one of many factors that shape social expectations of masculinity. Overall, ethnographers have demonstrated that masculine ideals, and the ways that men draw on and sometimes reject these ideals, cannot be reduced to stereotypical characteristics associated with machismo. Despite the problematic uses of machismo, Gutmann (1996) demonstrated that it remains important to interrogate this concept through ethnography. He showed that in a working class neighborhood in Mexico City, machismo remained a powerful force in shaping how men and women think about gender relations. That is, individuals made use of machismo to understand gender relations, even if machismo was insufficient for explaining how gender relations played out in their own lives. In Santa Cruz, whenever I heard the term machismo, it was typically to refer to negative traits associated with men and a male-dominated society. Positive qualities, such as the bravery and chivalry described by Gilmore (1990), typically did not enter the discourse. Individuals attributed actions such as wife beating, womanizing, and drinking too much to machismo. Those who embodied the traits associated with machismo are then labeled machistas. While individuals readily used machista as a label to describe another person, or even society as a whole, it was rarely a label that individuals used to self-identify. Although men were hesitant to use the term machista to describe themselves, people still viewed machismo as a force that influenced local gender relations, and they were quick to refer to others as machista. Further, machismo offered a set of behaviors that women come to expect of men and even view as socially acceptable. Even when a man is not described as machista, a man may make use of the cultural script of options for what men can and should do under given circumstances. This script was informed by societal understandings of machismo and other versions of masculinity. It allowed for the normalization of behaviors such as infidelity, violence against women, and excessive drinking even if people might simultaneously be critical of these behaviors. As a result, individuals came to expect little from the men in their lives, feeding into a strong social imaginary of Bolivian “men as disappointing, despite their displays of bravado and promises of protection” (Wright 2006:62). As the woman I rented a room from in Santa Cruz put it, “Here, men are worthless.” Thus, although multiple forms of masculinity exist, machismo continues to pervade social understandings of masculinity. The machista puts flesh on the concept of machismo. Ana, a 60-year-old woman who had recently received her diagnosis after her husband died of AIDS, evoked the imagery tied to the machista in describing her former husband as “controlling.” Her adult daughter insisted that he was a machista. Ana explained: He always liked to yell and fight and be in control of everything. He would yell because there wasn’t enough salt in the soup, or whatever little thing. My reaction was always to be calm. If I didn’t fight back, he had no one to

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fight with. Sometimes I cried, but I never fought back. … He always insisted that I stay in the house. He didn’t want me to go out with anyone or leave the house. But he was always out in the street. I never knew what he was doing. Maybe he had a double life, and that’s how he got this. We don’t know.

Later, Ana’s daughter added, “It was my idea that my mother take an HIV test. We never knew what my father had. He just got sick and didn’t want anyone to help him. But toward the end, I began to suspect it was AIDS. When her test came back positive, that’s how we knew for sure.”

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Blaming machismo as a gendered politics of life Since local HIV program funding and guidelines originate in the global health arena, it is important to examine the blaming machismo discourse alongside the global health context. Scholars such as Nguyen (2010) and Fassin (2009) described global health interventions as a politics of life, in which policies and processes define whose lives are worth saving. Nguyen (2010) applied this concept to analyze who could gain access to ARVs when they first became available in West Africa. This lens of analysis also forces a critical examination of the inequalities that define some lives as worth saving while neglecting others, creating what Farmer (2003) called a hierarchy of suffering that prioritizes some forms of suffering over others. With issues of gender intertwined with the AIDS epidemic, this presses the question of how gender plays into the policies of who has what type of access to services for HIV. During the early years of the epidemic worldwide, women were not portrayed as at risk, with a popular “rugged vagina” explanation for lower rates of HIV infection among heterosexuals (Langone 1985:41, cited in Treichler 1999). While ignoring women perpetuated the spread of HIV, the devastating impact of AIDS on women and children was eventually crucial in gaining support for HIV funding. The ‘innocent victim’ discourse that emerged played a central role in mobilizing large-scale global health responses to HIV, including mass treatment (Richey 2011). However, the innocent victim label implies the existence of a ‘victimizer’ or those who might ‘deserve’ to suffer. When global health messages surrounding HIV/AIDS intersect with notions of machismo, they result in strong sentiments of blame toward men. Statements such as “Cultural expectations of masculinity encourage men to assume the patriarchal attitude that wives, partners and daughters are the possessions of men, and most husbands expect or demand their conjugal ‘rights,’” which appeared in a UNAIDS publication on gender and HIV (2012:15), abound in global health documents. Local health care workers reframe this narrative based on local understandings of gender, with one doctor at a public HIV clinic slamming his fist on his desk as he told me, “The only people I feel sorry for are the women who come here [for HIV treatment] because they got it from their husbands!” In another instance, in a quote given to the media, a high-ranking public health official attributed epidemiological trends to “a machista culture where men continue to dominate and lead lives marked by irresponsibility toward their families and their health” (Pérez 2012). In a context of extreme gender inequalities, this narrative resonates with the experiences of many. For example, one man in his mid-fifties explained to me unapologetically, “My wife died from this in 2009. I gave it to her. I was with other women. We got along well, but I would go out with other women to dance and drink. And like that, I infected her.” Another married man and father of four told me in front of his wife, “I’m a person, who in my 36 years of life, I’ve lived a lot. … I’ve been with prostitutes, with maricones,2 with everyone. I’ve done bad things. But, there are things that I have changed and I’m living with the consequences of what I did. But I’m still a womanizer.” These examples make it very tempting to blame men. However, simply blaming men ignores the complexity in how gender inequalities play out, putting men and women at risk and shaping their experiences with the illness. The context of deaths from AIDS and men’s care seeking patterns brings to light some stark trends. In Santa Cruz, although men comprised 64% of newly registered cases of HIV in 2013, they accounted for 79% of AIDS deaths that same year (CDVIR 2013). Higher death rates from AIDS

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among men is somewhat expected, given that until recently the epidemic was more heavily concentrated among men. However, the only AIDS hospital in Santa Cruz owns a small plot in a cemetery where they bury abandoned patients. According to the hospital staff, men comprise almost all of those who are abandoned, even though women also frequently die at the hospital. At the largest public hospital in Santa Cruz and in the public hospitals in the satellite cities of Warnes and Montero,3 each doctor has a stack of medical files of individuals who had received an HIV diagnosis but had been ‘lost.’ At each of these hospitals, there are multiple stacks of files for men, but only a small stack for women. On a visit to the hospital in Warnes, the nurse began to count the files in her stacks as she explained to me what they represent. There were more than 20 files for men, four for women. “A lot of the men don’t come. Some send a wife or partner to pick up their medications, but the others just disappear,” she explained. A doctor at a public hospital in Santa Cruz explained that when a patient “disappears,” the death almost always goes unregistered as an AIDS-related death. Because of this, he suspects that the number of AIDS-related deaths is vastly underreported, especially for men. These trends bring to light several questions. First, why do so many men not seek care? Is there anything about the social imaginary regarding masculinity and HIV that shapes men’s care seeking patterns? How does a machismo blaming discourse shape the illness experiences of men with HIV? In Bolivia and elsewhere, health outcomes tend to be worse for men than for women, especially when it comes to managing chronic conditions (see Gavarkovs, Burke, and Petrella 2015 and Courtenay 2000 for overviews). For example, Gavarkovs and colleagues (2015) found that men are significantly less likely to participate in health management programs, even though they are significantly more likely to suffer from chronic conditions. Courtenay suggested that masculinity contributes to this phenomenon, with risky health behaviors and other social practices that undermine health at times serving as a means for men to demonstrate masculinity. Speaking specifically of Bolivia, Paulson and Baily (2003) pointed out that women in general are the targets of and have greater participation in reproductive health programs, where information is more readily available about HIV and other sexually transmitted infections. Because of this, men are less likely to receive prevention information and be offered HIV testing when seeking healthcare services. Thus, masculinity shapes health risks and health-seeking patterns. In this article, I consider how men internalize the blaming machismo discourse, and how this impacts their own understandings of their illness and their experiences seeking care.

Problematizing machismo In this section, I draw on the life histories of four men—José Carlos, Rafael, Efraín, and Aldo—to illustrate how their understandings of masculinity, coupled with machismo blaming, have shaped their care seeking patterns and illness experiences to varying degrees. All of these men were to some extent marginalized. Rafael, who was working class and grew up in a rural indigenous community, struggled economically throughout his life. José Carlos and Efraín both lived in poverty and experienced times living on the street. Aldo was raised in a middle-class urban family, but due to his sexual identity, he was marginalized within his family. The blaming of machismo that dominates HIV-related services harmed all of these men, but their narratives complicate understandings of how various forms of masculinity shape risk for HIV and experiences of living with the disease.

The maleante: José carlos and the gendered suffering of street life “I don’t understand why she abandoned me. It’s left me with this pain. I look for help from God, but I can’t escape the loneliness, the pain,” José Carlos said through tears, referring to his mother who abandoned him at a children’s home when he was eight years old. At the time, she was beginning a relationship with a new man who did not want to support a child that was not his.

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José Carlos continued: “Sometimes I think about going to look for my family, to try to forgive my mother. I haven’t seen my family in 13 years.” As he continued recounting his pain, my eyes shifted to the scars on his left arm. The dozens of horizontal scars that run down the inside of his arm, between his elbow and his wrist, are a physical reminder of his emotional suffering, of the dozens of times he has tried to end his life. The first time was when he was 12 years old. More recently, he tried a different method—pills. When José Carlos was 11 years old, he escaped from the children’s home saying, “I always wanted to be an adult. I wanted to start working. I thought if I had a job and showed my family I could contribute something, that they would want me back.” His mother had sometimes visited him at the children’s home, but he had not seen her since he left, when he began a life on the streets selling recyclables collected from trash, cleaning wind shields, and engaging in petty theft. When he was 12 years old, he smoked marijuana for the first time. He tried other drugs, but he continued to favor marijuana and alcohol—they relaxed him, helped him forget his pain. When even the drugs were not enough to make him forget, he cut himself. Apart from the scars of these moments, time on the street marked José Carlos’ body in other ways. He has two tattoos on his face, one of a marijuana leaf, that friends gave to him on different occasions when they were high. He has scars on his face and hands from fights. At some point, he contracted HIV. Eventually, José Carlos found what he thought was happiness. When he was 17 years old, he met a girl, Cecilia, who he describes as the love of his life. Together, they formed a life around their drug habits and finding enough money to support them. José Carlos continued to favor marijuana. Cecilia relied on pills. Sometimes, she would disappear for long periods and José Carlos would go crazy. As their relationship began to suffer, Cecilia came to him with news one day that she was HIV positive and that he should be tested. They stayed together for a while after this, but they began having more problems. He explained, “Then she left for Cochabamba. She never told me where she was going. After a month, I found out that’s where she was. I wanted to go find her, but I didn’t have any money. I wanted to die.” While Cecilia was in Cochabamba, the police arrested José Carlos. “I’ve done a lot of bad things,” José Carlos admitted. “But when the police arrested me that time, it was for something I didn’t do. Someone robbed a woman, and she paid the police so that they would find the person, so they had to find someone. They took me. … They told me they were taking me to a rehabilitation center. When we got there, I saw that it was Centro de Rehabilitación Palmasola.” José Carlos spent two and a half years in Palmasola prison. The Bolivian prison system is simultaneously hailed as a new model for prisons and criticized for widespread human rights abuses. While guards monitor the prison walls, there are no guards inside the prison blocks. Instead, an elected group of prisoners operates inside to maintain order. Prisoners must pay fees to stay in a cell and have a bed. Prisoners can bring in outside food, so many make and sell food from their cells. Those without money are the only ones who eat food provided by the prison, which often consists of no more than “hot water with salt,” according to José Carlos. Several Evangelical churches own prison cells, and by joining a church, prisoners often have more access to food, a bed, and protection. While it is easy to dismiss joining a church as pragmatic, José Carlos spoke of joining in more affective terms. “One day I started to pray, because that’s what they tell you to do. At first I didn’t feel anything, but then one day I felt a comfort, a love, that I had never felt before,” he explained. Following his release from prison, José Carlos entered a church-sponsored drug rehabilitation program. He was there about six months when he began developing symptoms of tuberculosis (TB). The church sent him to the local AIDS hospital, Comunidad Encuentro, where he stayed for eight months. I met him there in December 2013. When José Carlos was ready to leave the hospital in July 2014, Brother Emilio, who was in charge of the rehabilitation center, helped him find a room to rent. He found a church member who offered José Carlos a job at his restaurant, but when the church member saw the scars and tattoos on José Carlos’ face, he withdrew the offer. José Carlos found an alternative job in construction, but in the first two weeks of work, his boss failed to pay him as promised and a falling beam injured him. The

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last time I saw José Carlos, we went to eat. I knew he had only been eating the lunch they gave him at work and nothing else. He had quickly lost weight and his eye was swollen shut from his work injury. He began to cry, saying, “I know that God is testing me, that I have to be strong, but I don’t think I can suffer anything else.” I left José Carlos that day, extremely worried, but feeling impotent and unable to do anything. Two days later, I tried to call him. His phone was disconnected. I then called Brother Emilio, who was worried as well, saying he had not seen or heard from him. The next week, I returned to the United States. Our mutual contacts say they have not seen him and he has not picked up his ARVs. Without medications, José Carlos has likely died. According to a doctor at the government HIV clinic, men like José Carlos are the least likely to adhere to ARVs. Society labels these men maleantes, unworthy of any support. The maleante is similar to what Ferrándiz (2003) described as lower class urban men, or malandros, in Caracas, Venezuela. According to Ferrándiz (2003:116), malandros are viewed as “savages, barbarians, and parasites, people who are predisposed to random violence owing to little more than their ‘lack of character.’” Ferrándiz further added, “once out of his immediate urban territory, his shantytown, [he] frequently notices that others cross the street to avoid him, that merchants lock their shops when they spot him, that police officers comment on how he does not fit in and that they may reach for their guns or harass him, that taxi drivers speed away after refusing him a ride.” Thus, the maleante and malandro represent forms of masculinity that society assigns to poor, urban men. Ferrándiz described this as a form of wounded masculinity, in which men construct their identities around the violence and failure that characterize their everyday lives. Discourses of blaming machismo assume that men are always socially dominant, and frame gendered suffering as a uniquely female experience. This fails to recognize that men, especially those who are socially marginalized due to social class, race, and/or sexual identity, experience distinct gendered forms of suffering. In a context where female children are seen as useful assets around the house, able to clean, cook, and otherwise help, perhaps José Carlos’ mother’s new boyfriend would have been more open to raising a female child that was not his. Further, in Santa Cruz, it is extremely common for middle- and upper-class families to informally adopt an abandoned child, but they almost always choose an abandoned girl. Boys are left on the street, and escaping life on the street can be near impossible. For José Carlos, tattoos and scars were physical reminders that he was a maleante, perpetuating his suffering. Rafael and machismo as a risk factor Rafael is a 45-year-old man who migrated to Santa Cruz from the rural highlands in search of work following his military service in the 1980s. I first met him at Comunidad Encuentro in December 2013. At the time, he had already been there for several months, recovering from TB. After several weeks of stopping by to chat and watch TV with him, Rafael asked me, “Can I tell you my story?” “Of course,” I responded, “if you want to share it with me.” He began talking in a hushed voice, looking around to see who might overhear us in the shared room, then motioning for us to go outside. We sat in two wooden chairs, swatting away mosquitos as he began, “I don’t know if I really have this sickness that they tell me I have. I was never a womanizer. I’ve always worked and worked. When I was younger, I had relationships, but I was never a womanizer. It’s been years since I went out with a girl. I separated from my wife eight years ago, and I haven’t found anyone else.” He repeated several pieces of this narrative throughout our conversation—“I was never a womanizer” and “I don’t know if I really have this.” Rafael went on to tell me about his life: “I have a daughter, about your age, but she doesn’t want to come visit me. Her mother-in-law turned her against me.” He framed his life in terms of the various jobs he had as a laborer, trucker, and construction worker. I continued visiting Rafael whenever I went to Comunidad Encuentro. Although his doctor granted him permission to leave in April, he stayed until June, having nowhere else to go after

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losing his rented room when he could no longer work. At Comunidad Encuentro, the nurses invented tasks for him to do, such as repairing an IV hanger and fixing cracks in the cement sidewalk, to cure his thirst to work. Finally, one of the doctors gave him a job working on his property, giving Rafael the means to leave the hospital. Rafael’s illness narrative challenges the use of machismo as a risk factor. Rafael understood a key trait of machismo as being a womanizer, something he did not identify as. Instead of framing his masculinity through traits he associated with machismo, Rafael framed his masculinity in terms of work and his ability to work. HIV assaulted his masculinity in this way because it prevented him from being able to work. Because of how Rafael understood his masculinity coupled with viewing HIV as something tied to machismo, he did not see himself as at risk for HIV, and he did not believe his positive test result. In fact, it is unlikely that Rafael would have voluntarily taken an HIV test had he not become sick with TB. Rafael’s understanding of HIV as something that a man gets from being a machista contributed to his late diagnosis for HIV. The delay in diagnosis made his recovery from TB more difficult, and it would continue to make him susceptible to opportunistic infections, which could ultimately result in death while his immunity built up. Further, Rafael’s HIV diagnosis destroyed his relationship with his daughter—a key figure in his life. A blaming machismo discourse convinced his daughter that he was no longer worthy of her affection. Without her visits, and socially abandoned, I effectively became Rafael’s only visitor during the nearly nine months he stayed at Comunidad Encuentro.

Efraín and encounters with blaming machismo Efrain and I sat across from each other in wooden benches in the courtyard of his mother-in-law’s house on an overcast morning in the midst of the rainy season. This was my first time speaking at length with him, even though I had begun developing a close relationship with his partner several months earlier. Efrain began our conversation by recounting his frustrations with a local HIV activist group: I went to one forum, but after that, I decided I would never go again. You know why? Because they blame men for everything. They say HIV is because of machismo. But in my case, it was not like that. In my case, my wife infected me. … At one of the meetings that they always have, at the Hotel Misional or wherever, someone mentioned machismo, and I responded that it’s not always like this, that my wife infected me. I didn’t infect my wife. Everyone was yelling and angry. So, I decided to never go again.

Over nearly two hours, Efraín recounted his life history to me. Some of the details of his life seemed more like magical realism than real life, but his current partner, Magaly, confirmed the more hard-to-believe details. Central to Efraín’s narrative are the things that the women in his life had done to harm him, although Magaly often became angry with him when he blamed women, saying, “You are not so innocent yourself! And they are not here to defend themselves!” In other conversations I had with Magaly, she frequently cited Efrain’s machista behavior. However, such labels left him feeling angry and alienated. Efraín continued with his narrative by saying: “How I met her, the woman who gave me this … well, first you really need to know how I ended up in La Paz, where I met her. I went to La Paz to escape the mines, because I worked in the mines at the time. Before I went to work in the mines, I lived in Cochabamba. But after the mother of my children sold my child, that’s when I went to the mines.” “She sold your child?” I asked, trying not to show my horror. “Well, she sold both our children,” he continued, “I got the oldest one back, he is 14 now, you met him last week … I had a lot of problems with the mother of my two children. Sometimes we were together. Sometimes we weren’t. But after the second child, when my son was a baby, I decided I wanted to be with my family. One day, I went home after work, but no one was there.”

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A friend finally told Efrain that his wife had sold the children and used the money to escape to Peru. Desperate to find them, he went to the police and his parents for help. The story received widespread media attention. The police eventually found the baby, but they never found the twoyear-old son. Efraín’s parents, convinced he could not care for a child on his own, insisted on raising the son. Not sure what to do, Efraín decided to go to Oruro to look for work in the tin mines. This was dangerous work with inconsistent wages, so he quickly left for La Paz. There he met Lourdes, the mother of his youngest biological child. Magaly later told me that Efraín had met Lourdes in a red light district of El Alto, and he was fully aware that she was a sex worker when they began a relationship. Efraín continued to have trouble finding work, but his relatives encouraged him to come to Santa Cruz. The day after he and Lourdes arrived in Santa Cruz, he had work. Describing the progression of their relationship once in Santa Cruz, he said: She never told me that she had this sickness, but thinking about things that happened, she had to know. She always wanted me to use a condom, but since I didn’t know she had this, I didn’t want to. I wanted a child with her, but she said she didn’t want one, and when she got pregnant the first time, she had an abortion. The second time she got pregnant, I convinced her to have the child, but she insisted on a C-section. She borrowed 1500 bolivianos4 from a relative to have the C-section because she refused to go to the public maternity hospital … she did not want to breastfeed him. Since I didn’t know why, I insisted that she breastfeed him. I always heard that breast milk is best, so I did what I thought was right. I think that is how she transmitted it to him.

In the first year after his son was born, Efraín began to get sick a lot. He had chronic diarrhea to the point that he was unable to get out of bed. He went to a laboratory where they tested him for “everything,” but not HIV. He then developed a knot on the back of his head, which left one side of his body paralyzed. Unable to get out of bed for months, his grandfather finally sought the advice of a traditional healer, as Efraín explained: The healer told my grandfather to go to La Paz to buy mule fat, so he went, and came back with a jar of it. They heated the fat until it was a liquid, then they put it all over my body. I lay on the ground outside the house, and they massaged it all over me and left me in the sun. They repeated the same thing three times. Then I was better. With nothing else, I got better.

Once Efraín recovered, however, Lourdes began to get seriously ill. Near death, Lourdes insisted on returning to La Paz so that her family could help take care of her. In La Paz, she deteriorated further. Finally, while she was hospitalized, a nurse advised Efain and his son to “go to this place” to get tests, although she did not specify which tests. The address she sent him to was to the government HIV clinic; both tested positive. This was in 2008, and ARVs were available for Efraín and his son. Lourdes died, and although Efraín seems certain that Lourdes had HIV before him, her parents blame him for her death. They received custody of the son and forbid Efraín from visiting. Efraín has tried several times to get custody, without success. In their meta-analysis of more than 13,000 sero-discordant couples in sub-Saharan Africa, Eyawo and colleagues (2010) found that women were equally as likely as men to be the partner with HIV. Despite this, perceptions persist that men are the source of HIV infection within relationships. Such perceptions shape how HIV positive men are viewed by society, as reflected by Efraín’s experiences. Additionally, I often heard machismo drawn on by public health officials to explain why men do not want to use condoms. Efraín, however, spoke of his desire to form a family with Lourdes as shaping his unwillingness to use a condom. Far from the story of a cheating husband who gives his wife HIV, implied by the social imaginary of the machista, many pieces of Efraín’s narrative demonstrate complex routes in how gender inequalities shape risk and vulnerability to HIV. Magaly was always quick to defend Lourdes, saying that she had to become a sex worker because her parents could not support the family, acknowledging the gender inequalities that can constrain women’s agency surrounding sexual relationships. Efraín’s insistence that Lourdes have a child, his refusal to use a condom so that she would become

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pregnant, and his insistence that she breastfeed their child, suggest a relationship marked by male domination. It is also important to consider if and how gender inequalities influence partner disclosure: Lourdes never disclosed her status to Efraín. Even if gender inequalities are evident in Efraín’s relationships with women, he takes offense at the suggestion that machismo is the cause of his condition, and he has felt shut out of activist programs when he fails to agree with the message that machismo is to blame for the spread of HIV.

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Aldo and the traumas of machismo How social constructions of machismo shape the experiences of men who identify as gay is particularly complex. Many Bolivian men who engage in same-sex relationships do not identify as gay, and as Wright (2006) demonstrated, sexual identities and practices are often contextual. Next I focus on Aldo, who identifies as gay, recognizing that his encounters with machismo are different from those of men who engage in same-sex relationships without adopting a gay identity. As a 46-year-old self-identifying gay man, Aldo simultaneously feels harmed by expressions of machismo and the constant need to prove that he is a man. For part of the time that I knew him, Aldo was in a drug rehabilitation center, which he described as a machista environment filled with machistas. He felt constant assaults on his masculinity, one time mentioning a film featuring a transvestite that the men watched together in the center. He explained that during the film, “The men all started laughing and whispering comments about me. People here think that because I’m gay, I want to be a woman, that I am more feminine. But I am a man. I am attracted to men, but I never wanted to be a woman. I never dressed in women’s clothes. I never wanted breasts.” Aldo and several other self-identifying gay men also applied the term machista to women. Aldo used this term to describe his mother and other women in his life who rejected him for his homosexuality. Aldo said of a woman from whom he rented a room for a brief period: “She was more machista than any man. She was a friend of my mother’s. … She talked a lot about witchcraft, saying that it was witchcraft that made me the way I am. … I always felt this pressure in my life somehow.” Aldo felt constant rejection from his family and inadequate as a ‘real’ man. He explained his need to self-medicate and addiction as the result of his mother’s rejection, her refusal to accept that she had a homosexual son. Through his addiction, he became involved in narcotrafficking, which took him on 21 trips to Europe, the United States, and Thailand. In Europe and the United States, he encountered different societal responses to homosexuality, ones that he now draws on to explain Bolivian society as machista. However, Aldo’s addiction, and his HIV diagnosis, eventually brought him back to Bolivia where he has been in and out of rehab centers for several years. He expresses a constant desire to change and for his life to be different, but the pain he feels from his family and a society that view him as a failed man overwhelm him at times, fueling his addiction.

Conclusion: Rethinking machismo as a risk factor My goal in this article was to problematize the ways that machismo is constructed and drawn upon in discussions of HIV prevention and care. Constructing machismo as a risk factor implies that it is the machista who is at risk. Individuals tie the concept of machismo to a caricature machista that exists more in the social imaginary than in reality. When men do not view themselves as a machista, they often fail to see how they are at risk for HIV, as illustrated by Rafael. Further, by not seeing himself as at risk, Rafael doubted his diagnosis, with implications for him staying in care. Efraín’s experiences demonstrate the harm that can come from blaming machismo. Although he exhibited behaviors that clearly reinforced gender inequalities between himself and the women in his life, machismo blaming left him feeling excluded by some HIV-related services. Further, while public health officials often draw on machismo to explain men’s reluctance to use condoms, Efrain’s narrative demonstrates that men’s desires to have families also influence condom use. José Carlos’ and Aldo’s experiences provide examples of failed forms of masculinity, which stand in contrast to machismo and also shape risk and experiences of living with

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HIV. They demonstrate that gendered forms of suffering also exist for men. The marginalization and exclusion they felt presented them with a distinct set of challenges for staying in care. Every time Aldo spiraled into old drug habits, for example, he also fell out of care. Jose Carlos, labeled as pathological by society, could not find work and was left with no regular income and no support. The ways that local gender ideologies intersect with a global health master narrative that emphasizes women’s vulnerability to HIV contributes to a reliance on the concept of machismo to explain away epidemiological patterns. As I demonstrate elsewhere (Heckert 2015), the master narrative also harms women, especially when women do not identify with the ‘victim’ role. Illness narratives of men complicate understandings of masculinity as it relates to HIV/AIDS, demonstrating the complex ways that men’s own understandings of their masculinity shape risk and experiences of living with HIV, especially when these understandings clash with the master narrative and the social imaginary. Blaming machismo contributes to late testing, not participating in services that are available, and falling out of care, which are ultimately matters of life and death.

Notes 1. This figure reflects reported cases of HIV. Some research suggests that the prevalence rate may be significantly higher, but a lack of access to healthcare combined with low HIV testing rates could contribute to many cases going undiagnosed. For example, a 2008 UNAIDS estimate suggested that there were 17,000 HIV cases in Bolivia at a time when there were only 2,905 cases registered since 1985 (CDVIR 2011). 2. Maricones is used generally to refer to gay men. In sexual encounters with maricones, other men view maricones as females in the relationship, enabling the ‘man’ to maintain his heterosexual identity (Wright 2006). 3. Epidemiological data indicate that rural areas and satellite cities have consistently had a balanced sex ratio in new cases of HIV, even during earlier years of the epidemic when new cases at the national level were concentrated among men (CDVIR 2013). 4. Bolivian currency, equal to $217.

Acknowledgments I am grateful to the individuals whose narratives appear in this article, who willingly shared their time and stories with me. I would also like to thank Nia Parson, Caroline Brettell, Carolyn Smith-Morris, Timothy Wright, and the three anonymous reviewers, who provided constructive feedback on this article during its various stages of development.

Funding A Wenner-Gren Foundation Dissertation Fieldwork Grant and an Edward Fry Award from the Department of Anthropology at Southern Methodist University funded this research.

Notes on contributor Carina Heckert is assistant professor of Anthropology at the University of Texas at El Paso. Currently, she is working on a book manuscript tentatively titled Aiding Women: The Gendered Politics of Life during an AIDS Funding Crisis. Her research interests include health policy, gender based violence, immigration and health, and HIV/AIDS.

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