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Robson I, Mphande M, Lee J, Hubbard JA, Daniels J, Phiri K, Chikuse E, Coates TJ, Cornell M, Dovel K. Implementing a male-specific ART counselling curriculum: a quality assessment with healthcare workers in Malawi. J Int AIDS Soc 2024; 27:e26270. [PMID: 39039724 PMCID: PMC11263468 DOI: 10.1002/jia2.26270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 04/29/2024] [Indexed: 07/24/2024] Open
Abstract
INTRODUCTION There is little HIV counselling that directly meets the needs of men in Eastern and Southern Africa, limiting men's knowledge about the benefits of HIV treatment and how to overcome barriers to engagement, contributing to poorer HIV-related outcomes than women. Male-specific approaches are needed to improve men's outcomes but may be difficult for healthcare workers (HCWs) to implement with fidelity and quality in low-resource settings. We developed a male-specific counselling curriculum which was implemented by male HCWs and then conducted a mixed-methods quality assessment. METHODS We audio-recorded counselling sessions to assess the quality of implementation (n = 50) by male HCWs from two cadres (nurse, n = 10 and lay cadre, n = 10) and conducted focus group discussions (FGDs) with HCWs at 6 and 9 months after rollout to understand barriers and facilitators to implementation. Counselling sessions and FGDs were translated, transcribed and analysed using thematic analysis adapted from WHO Quality Counselling Guidelines. We assessed if sessions were respectful, informative, interactive, motivating and included tailored action plans for overcoming barriers to care. All data were collected September 2021-June 2022. RESULTS All sessions used respectful, non-judgemental language. Sessions were highly interactive with most HCWs frequently asking open-ended questions (n = 46, 92%) and often incorporating motivational explanations of how antiretroviral therapy contributes to life goals (n = 42, 84%). Few sessions included individually tailored action plans for clients to overcome barriers to care (n = 9, 18%). New counselling themes were well covered; however, occasionally themes of self-compassion and safe sex were not covered during sessions (n = 16 and n = 11). HCWs believed that having male HCWs conduct counselling, ongoing professional development and keeping detailed counselling notes facilitated quality implementation. Perceived barriers included curriculum length and client hesitancy to participate in action plan development. Findings were similar across cadres. CONCLUSIONS Implementing high-quality male-specific counselling using male nurses and/or lay cadre is feasible. Efforts to utilize lay cadres should be prioritized, particularly in low-resource settings. Programmes should provide comprehensive job aids to support HCWs. Ongoing training and professional development are needed to (1) improve HCWs' skills in tailored action plans, and (2) sensitize HCWs to the need for self-compassion within male clients to promote holistic sexual health.
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Affiliation(s)
- Isabella Robson
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
- Implementation Science DepartmentPartners in HopeLilongweMalawi
| | - Misheck Mphande
- Implementation Science DepartmentPartners in HopeLilongweMalawi
| | - Jiyoung Lee
- David Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - Julie Anne Hubbard
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - Joseph Daniels
- Edson College of Nursing and Health InnovationArizona State UniversityPhoenixArizonaUSA
| | - Khumbo Phiri
- Implementation Science DepartmentPartners in HopeLilongweMalawi
| | - Elijah Chikuse
- Implementation Science DepartmentPartners in HopeLilongweMalawi
| | - Thomas J. Coates
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
- University of California Global Health InstituteSan FranciscoCaliforniaUSA
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Kathryn Dovel
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
- Implementation Science DepartmentPartners in HopeLilongweMalawi
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Mphande M, Robson I, Hubbard J, Chikuse E, Lungu E, Phiri K, Cornell M, Phiri S, Coates TJ, Dovel K. Developing a male-specific counselling curriculum for HIV treatment in Malawi. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.08.23293583. [PMID: 37609294 PMCID: PMC10441488 DOI: 10.1101/2023.08.08.23293583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Men living with HIV in sub-Saharan Africa have sub-optimal engagement in antiretroviral therapy (ART) Programs. Generic ART counselling curriculum in Malawi does not meet men's needs and should be tailored to men. We developed a male-specific ART counselling curriculum, adapted from the Malawi Ministry of Health (MOH) curriculum based on literature review of men's needs and motivations for treatment. The curriculum was piloted through group counselling with men in 6 communities in Malawi, with focus group discussion (FGD) conducted immediately afterward (n=85 men) to assess knowledge of ART, motivators and barriers to care, and perceptions of the male-specific curriculum. Data were analysed in Atlas.ti using grounded theory. We conducted a half-day meeting with MOH and partner stakeholders to finalize the curriculum (n=5). The male-specific curriculum adapted three existing topics from generic counselling curriculum (status disclosure, treatment as prevention, and ART side effects) and added four new topics (how treatment contributes to men's goals, feeling healthy on treatment, navigating health systems, and self-compassion for the cyclical nature of lifelong treatment. Key motivators for men were embedded throughout the curriculum and included: family wellbeing, having additional children, financially stability, and earning/keeping respect. During the pilot, men reported having little understanding of how ART contributed to their personal goals prior to the male-specific counselling. Men were most interested in additional information about treatment as prevention, benefits of disclosure/social support beyond their sexual partner, how to navigate health systems, and side effects with new regimens. Respondents stated that the male-specific counselling challenged the idea that men were incapable of overcoming treatment barriers and lifelong medication. Male-specific ART counselling curriculum is needed to address men's specific needs. In Malawi context, topics should include: how treatment contributes to men's goals, navigating health systems, self-compassion/patience for lifelong treatment, and taking treatment while healthy.
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Angotti N, Mojola SA, Wen Y, Ferdinando A. Biomedical bargains: Negotiating "safe sex" on antiretroviral treatment in rural South Africa. Soc Sci Med 2023; 330:116036. [PMID: 37390807 DOI: 10.1016/j.socscimed.2023.116036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 07/02/2023]
Abstract
Wide-scale availability of antiretroviral treatment (ART) has transformed the global landscape for HIV prevention, shifting emphasis away from a strictly behavioral focus on changing sexual practices towards a biomedical approach. Successful ART management is measured by an undetectable viral load, which helps maintain overall health and prevent onward viral transmission. The latter utility of ART, however, must be understood in the context of its implementation. In South Africa, ART has become easily accessible - yet ART knowledge spreads unevenly, while counseling advice and normative expectations and experiences of gender and aging interact to inform sexual practices. As ART enters the sexual lives of middle-aged and older people living with HIV (MOPLH), a population growing rapidly, how has it informed sexual decisions and negotiations? Drawing on in-depth interviews with MOPLH on ART, corroborated with focus group discussions and national ART-related policies and guidelines, we find that for MOPLH, sexual decisions increasingly feature compliance with biomedical directives and concern for ART efficacy. Seeking consensus regarding the biological risks of sex on ART becomes an important feature of sexual negotiations, and anticipated disagreements can pre-empt sexual relationships altogether. We introduce the concept of biomedical bargains to explain what happens when disagreements arise, and the terms of sex are negotiated using competing interpretations of biomedical information. For both men and women, ostensibly gender-neutral biomedical discourses provide new discursive resources and strategies for sexual decisions and negotiations, yet biomedical bargains are still embedded in gender dynamics-women invoke the dangers of jeopardizing treatment efficacy and longevity to insist on condoms or justify abstinence, while men utilize biomedical arguments in an effort to render condomless sex safe. While the full therapeutic benefits of ART are critical for the efficacy and equity of HIV programs, they will nonetheless always affect, and be affected by, social life.
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Affiliation(s)
- Nicole Angotti
- Department of Sociology, American University, USA; MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Sanyu A Mojola
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Sociology, Princeton University, USA; School of Public and International Affairs, and Office of Population Research, Princeton University, USA
| | - Yunhan Wen
- Department of Sociology, Princeton University, USA
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Smith PJ, Daniels J, Bekker LG, Medina-Marino A. What motivated men to start PrEP? A cross-section of men starting PrEP in Buffalo city municipality, South Africa. BMC Public Health 2023; 23:418. [PMID: 36864381 PMCID: PMC9979577 DOI: 10.1186/s12889-023-15306-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 02/21/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Compared to women, South African men are less likely to know their HIV status (78% vs. 89%), have suppressed viral loads (82% vs. 90%), or access HIV prevention services. To achieve epidemic control where heterosexual sexual behavior drives transmission, interventions to improve the uptake of HIV testing services (HTS) and prevention services must also target cis-gendered, heterosexual men. There is limited understanding of these men's needs and wants with regards to accessing pre-exposure prophylaxis (PrEP). METHODS Adult men (≥ 18 years) from a peri-urban community in Buffalo City Municipality were offered community-based HTS. Those who received a negative HIV test result were offered community-based, same-day oral PrEP initiation. Men initiating PrEP were invited to participate in a study exploring men's HIV prevention needs and reasons for initiating PrEP. An in-depth interview guide, developed using the Network-Individual-Resources model (NIRM), explored men's perceived HIV acquisition risk, prevention needs, and preferences for PrEP initiation. Interviews were conducted by a trained interviewer in isiXhosa or English, audio-recorded and transcribed. Thematic analysis was used, guided by the NIRM to generate findings. RESULTS Twenty-two men (age range 18-57 years) initiated PrEP and consented to study participation. Men reported elevated HIV acquisition risk associated with alcohol use and condom-less sex with multiple partners as facilitators driving PrEP initiation. They anticipated social support from family members, their main sexual partner and close friends for their PrEP use, and discussed other men as important sources of support for PrEP initiation. Nearly all men expressed positive views of people using PrEP. Participants believed HIV testing would be a barrier for men interested in accessing PrEP. Men recommended that access to PrEP be convenient, rapid, and community-based (i.e., not clinic-based). DISCUSSION Self-perceived risk for HIV acquisition was a major facilitator for men's PrEP initiation. Although men expressed positive perceptions of PrEP users, they noted that HIV testing may be a barrier to PrEP initiation. Finally, men recommended convenient access points to facilitate PrEP initiation and sustained use. Gender-responsive interventions tailored to men's needs, wants, and voices will facilitate their uptake of HIV prevention services, and help to end the HIV epidemic.
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Affiliation(s)
- Philip John Smith
- The Desmond Tutu HIV Centre, University of Cape Town, Observatory, Cape Town, South Africa.
| | - Joseph Daniels
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Observatory, Cape Town, South Africa
| | - Andrew Medina-Marino
- The Desmond Tutu HIV Centre, University of Cape Town, Observatory, Cape Town, South Africa.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Research Unit, Foundation for Professional Development, Eastern Cape Province, 10 Rochester Rd, Vincent, East, London, Buffalo City Metro, South Africa.
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Medina-Marino A, Bezuidenhout D, Ngcelwane N, Cornell M, Wainberg M, Beyrer C, Bekker LG, Daniels J. Qualitative Identification of Intervention Preferences to Support Men's Engagement and Retention in TB Care in South Africa. Am J Mens Health 2022; 16:15579883221129349. [PMID: 36218175 PMCID: PMC9558889 DOI: 10.1177/15579883221129349] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Globally and in South African specifically, men account for 56% and 62% of all tuberculosis (TB) cases, respectively. Men are at increased risk of not accessing TB testing or treatment, and having poor treatment outcomes. Unfortunately, no interventions exist to address these issues. Toward the development of targeted, patient-centered TB care and support interventions, we used semistructured interviews to explored men's social network composition, TB testing behaviors, disclosure and treatment support, clinical experiences, and TB's influence on daily living. Data were analyzed using a thematic approach guided by the Network Individual Resource Model to identify mental and tangible resources influential and preferred during engagement in TB treatment. Men emphasized the desire for peer-to-peer support to navigate TB-related stigma and unhealthy masculinity norms. Men advocated for awareness events to educate communities about their challenges with TB. Men strongly suggested that interventions be delivered in familiar locations where men congregate. Since 2022, no TB treatment support interventions have included the preferred components or delivery modes described by men in our study. To improve men's TB-related health outcomes, the global TB community must identify and address men's unique challenges when designing interventions.
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Affiliation(s)
- Andrew Medina-Marino
- Division of Men’s Health, Desmond Tutu
HIV Centre, University of Cape Town, Cape Town, South Africa,Perelman School of Medicine, University
of Pennsylvania, Philadelphia, PA, USA,Research Unit, Foundation for
Professional Development, East London, South Africa,Andrew Medina-Marino, Division of Men’s
Health, Desmond Tutu HIV Centre, University of Cape Town, Cape Town, 7915, South
Africa.
| | - Dana Bezuidenhout
- Research Unit, Foundation for
Professional Development, East London, South Africa,Department of Epidemiology, Mailman
School of Public Health, Columbia University, New York City, NY, USA
| | - Nondumiso Ngcelwane
- Buffalo City Health District, Eastern
Cape Provincial Department of Health, Bisho, South Africa
| | - Morna Cornell
- School of Public Health & Family
Medicine, University of Cape Town, Cape Town, South Africa
| | - Milton Wainberg
- Department of Psychiatry, Columbia
University Vagelos College of Physicians and Surgeons, New York City, NY, USA,New York State Psychiatric Institute,
New York City, NY, USA
| | - Chris Beyrer
- Duke Global Health Institute, Duke
University, Durham, NC, USA,Desmond Tutu HIV Centre, University
of Cape Town, Cape Town, South Africa
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University
of Cape Town, Cape Town, South Africa
| | - Joseph Daniels
- Edson College of Nursing and Health
Innovation, Arizona State University, Phoenix, AZ, USA
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Mshweshwe-Pakela NT, Mabuto T, Shankland L, Fischer A, Tsukudu D, Hoffmann CJ. Digitally supported HIV self-testing increases facility-based HIV testing capacity in Ekurhuleni, South Africa. South Afr J HIV Med 2022; 23:1352. [PMID: 35923609 PMCID: PMC9257703 DOI: 10.4102/sajhivmed.v23i1.1352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/24/2022] [Indexed: 12/03/2022] Open
Abstract
Background HIV testing is the first step for linkage to HIV prevention or treatment services. Facility-based HIV testing is the most utilised method, but faces challenges such as limited work space and human resources. Digitally supported HIV self-testing (HIVST) provided in clinics shifts testing to the client, potentially empowering the client, and addresses such constraints. Objectives The study primary objective was to determine the feasibility of integrating digitally supported HIVST into the clinic. Secondary objectives were to describe HIV testing volume, populations reached, and antiretroviral treatment (ART) initiation. Method We conducted an analysis of prospectively collected data during implementation of digitally supported HIVST in two healthcare facilities based in South Africa from June 2019 to September 2019. We described implementation and client characteristics using HIVST and compared testing before and during implementation. Results During the 4-month implementation period there were 35 248 client visits. A total of 6997 (19.9%) of these visits involved HIV testing. Of those testing, 2278 (32.5%) used HIVST. Of the 2267 analysed, 264 (11.6%) were positive: 182 (12%) women and 82 (11%) men. Of those, 230 (95.4%) were confirmed HIV positive and 150 (65%) initiated ART within 14 days. During a four-month pre-implementation period, 14.5% of the clients tested for HIV. Compared to the pre-implementation period, we observed a 25% increase in HIV testing. Conclusion Digitally supported HIVST increased the number of clients completing HIV testing in the health facility, without a need to significantly increase staff or space. Facility-based digitally assisted HIVST has the potential to increase HIV testing in high HIV prevalence clinic populations.
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Affiliation(s)
- Nolundi T Mshweshwe-Pakela
- Department of Implementation Research, The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand Johannesburg, South Africa
| | - Tonderai Mabuto
- Department of Implementation Research, The Aurum Institute, Johannesburg, South Africa
| | | | | | - Dikeledi Tsukudu
- Department of Health Systems, The Aurum Institute, Johannesburg, South Africa
| | - Christopher J Hoffmann
- Department of Implementation Research, The Aurum Institute, Johannesburg, South Africa
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, United States of America
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
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Bor J, Onoya D, Richman B, Mayer KH. A Failure to Disseminate Transformative Science - HIV Treatment as Prevention, 10 Years On. N Engl J Med 2021; 385:2305-2307. [PMID: 34890175 PMCID: PMC9354720 DOI: 10.1056/nejmp2113118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Jacob Bor
- From the Department of Global Health, Boston University School of Public Health (J.B.), and the Fenway Institute (K.H.M.) - both in Boston; the Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg (D.O.); and the Prevention Access Campaign, New York (B.R.)
| | - Dorina Onoya
- From the Department of Global Health, Boston University School of Public Health (J.B.), and the Fenway Institute (K.H.M.) - both in Boston; the Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg (D.O.); and the Prevention Access Campaign, New York (B.R.)
| | - Bruce Richman
- From the Department of Global Health, Boston University School of Public Health (J.B.), and the Fenway Institute (K.H.M.) - both in Boston; the Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg (D.O.); and the Prevention Access Campaign, New York (B.R.)
| | - Kenneth H Mayer
- From the Department of Global Health, Boston University School of Public Health (J.B.), and the Fenway Institute (K.H.M.) - both in Boston; the Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg (D.O.); and the Prevention Access Campaign, New York (B.R.)
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