Gender and HIV testing in Burkina Faso: an exploratory study

Innovations in Providing HIV Index Testing Services: A Retrospective Evaluation of Partner Elicitation Models in Southern Nigeria

Background: This analysis aimed to evaluate the effectiveness of eliciting sexual partners from HIV-positive clients using the elicitation box model (where an HIV-positive index can report sexual contacts on paper and insert in a box for a health care provider to contact at a later time) compared to the conventional model (in which a health care provider elicits sexual contacts directly from clients) in Akwa Ibom, Southern Nigeria.Methods: Between March 2021 and April 2022, data were collected from index testing registers at 4 health facilities with a high volume of HIV clients currently on treatment in 4 local government areas in Akwa Ibom State. Primary outcome analyzed was the elicitation ratio (number of partners elicited per HIV-index offered index testing services). Secondary outcomes were the index testing acceptance (index HIV-positive clients accepted index testing service), testing coverage (partners tested for HIV from a list of partners elicited from HIV-index accepted index testing services), testing yield (index partners identified HIV positive from index partners HIV-tested), and linkage rate (index partners identified HIV positive and linked to antiretroviral therapy).Results: Of the total 2,705 index clients offered index testing services, 91.9% accepted, with 2,043 and 439 indexes opting for conventional elicitation and elicitation box models, respectively. A total of 3,796 sexual contacts were elicited: 2,546 using the conventional model (elicitation ratio=1:1) and 1,250 using the elicitation box model (elicitation ratio=1:3). Testing coverage was significantly higher in the conventional compared to the elicitation box model (P<.001). However, there was no significant difference in the testing yield (P=.81) and linkage rate using the conventional compared to elicitation box models (P=.13).Conclusion: The implementation of the elicitation box model resulted in an increase in partner elicitation compared to the conventional model. Increasing the testing coverage by implementing the elicitation box model should be considered.

Organisation of testing services, structural barriers and facilitators of routine HIV self-testing during sexually transmitted infection consultations: a qualitative study of patients and providers in Abidjan, Côte d'Ivoire

BACKGROUND

Consultations for sexually transmitted infection (STI) provide an opportunity to offer HIV testing to both patients and their partners. This study describes the organisation of HIV self-testing (HIVST) distribution during STI consultations in Abidjan (Côte d'Ivoire) and analyse the perceived barriers and facilitators associated with the use and redistribution of HIVST kits by STI patients.

MATERIALS AND METHODS

A qualitative study was conducted between March and August 2021 to investigate three services providing HIVST: an antenatal care clinic (ANC), a general health centre that also provided STI consultations, and a dedicated STI clinic. Data were collected through observations of medical consultations with STI patients (N = 98) and interviews with both health professionals involved in HIVST distribution (N = 18) and STI patients who received HIVST kits for their partners (N = 20).

RESULTS

In the ANC clinic, HIV testing was routinely offered during the first prenatal visit. HIVST was commonly offered to women who had been diagnosed with an STI for their partner's use (27/29 observations). In the general health centre, two parallel pathways coexisted: before the consultation, a risk assessment tool was used to offer HIV testing to eligible patients and, after the consultation, patients who had been diagnosed with an STI were referred to a care assistant for HIVST. Due to this HIV testing patient flow, few offers of HIV testing and HIVST were made in this setting (3/16). At the dedicated STI clinic, an HIVST video was played in the waiting room. According to the health professionals interviewed, this video helped reduce the time required to offer HIVST after the consultation. Task-shifting was implemented there: patients were referred to a nurse for HIV testing, and HIVST was commonly offered to STI patients for their partners' use (28/53). When an HIVST was offered, it was generally accepted (54/58). Both health professionals and patients perceived HIVST positively despite experiencing a few difficulties with respect to offering HIVST to partners and structural barriers associated with the organisation of services.

CONCLUSION

The organisation of patient flow and task-shifting influenced HIV testing and offers of HIVST kits. Proposing HIVST is more systematic when HIV testing is routinely offered to all patients. Successful integration requires improving the organisation of services, including task-shifting.

Social Support, Food Insecurity, and HIV Stigma Among Men Living with HIV in Rural Southwestern Uganda: A Cross-Sectional Analysis

BACKGROUND

HIV stigma is one of the major barriers to HIV care due to the fear of disclosure and social discrimination. HIV stigma among men in sub-Saharan countries, including Uganda, has been linked to the fear about how HIV status might affect their status in society. HIV among men in sub-Saharan settings has been associated with feelings of shame, reduced self-worth, and self-blame for their HIV positive status. Information about HIV stigma and its associated factors among men living with HIV in rural Uganda is limited. This study assessed the burden of HIV stigma and its association with social support and food insecurity among men accessing HIV care at a rural health facility in southwestern Uganda.

METHODS

We conducted a clinic-based cross-sectional study and consecutively enrolled 252 adult men accessing HIV care at a rural health centre in southwestern Uganda. We collected information on sociodemographic information, HIV stigma, social support, and food insecurity. We fitted modified Poisson regression models to determine the associations between social support, food insecurity, and HIV stigma.

RESULTS

The mean HIV stigma score of the study participants was 70.08 (SD 19.34) and 75% reported food insecurity 5% of whom were severely food insecure. The risk of HIV stigma was lower among those aged 35 years and above (adjusted risk ratio [ARR]=0.89; 95% CI 0.83-0.96; P=0.003, those who had been on ART for more than 5 years (ARR=0.92; 95% CI=0.84-0.99; P=0.04), and those who had social support (ARR=0.99; 95% CI=0.98-0.99; P=<0.001). Food insecurity was associated with an increased risk of HIV stigma (ARR=1.07; 95% CI 1.00-1.15; P=0.03). Social support moderated the effect of food insecurity on HIV stigma (P=0.45).

CONCLUSION

Stigma is common among men living with HIV in rural Uganda and is significantly associated with food insecurity. Social support moderated the effect of severe food insecurity on HIV stigma among men living with HIV. Interventions to build social support systems and to economically empower men living with HIV should be incorporated into the mainstream HIV care clinics.

Understanding the role of interpersonal violence in assisted partner notification for HIV: a mixed-methods study in refugee settlements in West Nile Uganda

BACKGROUND

Assisted partner notification (APN) for HIV was introduced in refugee settlements in West Nile Uganda in 2018 to facilitate testing of sexual partners. While APN is an effective strategy recommended by the World Health Organization, its safety has not been evaluated in a refugee settlement context in which participants have high prior exposure to interpersonal violence. The extent to which interpersonal violence influences APN utilization and the frequency with which post-APN interpersonal violence occurs remains unknown.

METHODS

To explore the relationship between APN and interpersonal violence, a cross-sectional mixed-methods study was conducted at 11 health centers in refugee settlements in West Nile Uganda. Routinely collected index client and sexual partner data were extracted from APN registers and semi-structured interviews were conducted with health workers.

RESULTS

Through APN, 1126 partners of 882 distinct index clients were identified. For 8% (75/958) of partners, index clients reported a history of intimate partner violence (IPV). For 20% (226/1126) of partners, index clients were screened for post-APN IPV; 8 cases were reported of which 88% (7/8) concerned partners with whom index clients reported prior history of IPV. In qualitative interviews (N = 32), health workers reported HIV disclosure-related physical, sexual and psychological violence and deprivation or neglect. Incidents of disclosure-related violence against health workers and dependents of index clients were also reported. Fear of disclosure-related violence was identified as a major barrier to APN that prevents index clients from listing sexual partners.

CONCLUSIONS

Incidents of interpersonal violence have been reported following HIV-disclosure and fear of interpersonal violence strongly influences APN participation. Addressing HIV perception and stigma may contribute to APN uptake and program safety. Prospective research on interpersonal violence involving index clients and sexual partners in refugee settlements is needed to facilitate safe engagement in APN for this vulnerable population.

HIV index testing services in urban Lusaka: a retrospective review of medical records

Background: As the proportions of people living with HIV (PLHIV) who do not know their HIV infection status decrease, reaching the remaining few who are asymptomatic and not in contact with the health care system becomes a critical challenge. Therefore, reaching the first 90 of the UNAIDS 90-90-90 targets will require effective and efficient HIV testing approaches. The number of PLHIV who know their HIV status and who receive antiretroviral therapy could increase by the expansion of index testing services. Methods: This project was a retrospective study looking at medical records of HIV positive clients who were elicited for index testing between October and December 2019. It was conducted in three high volume health facilities in Matero Urban sub-district 3 in Lusaka, Zambia. Results: The HIV test outcomes for index contacts were as follows: 452 index contacts (53.5%) tested HIV negative, 113 index contacts (13.4%) tested HIV positive, 108 index contacts (12.8%) were known HIV positive, and 172 index contacts (20.4%) were not yet tested for HIV. Of the 113 contacts who tested HIV positive, 90 index contacts started anti-retroviral therapy within 7 days (79.6%). The total number of 845 contacts were elicited from 604 index clients, giving a low elicitation ratio of 1:1.4. There was not much difference between gender for elicited contacts (423 men and 422 women). A total number of 565 index contacts were eligible for HIV test. 113 of them tested HIV positive, representing a positivity yield of 20%. Pearson Chi-Square test value was 0.498 and the p value was 0.481. This result is not significant since p value (0.481) is greater than the designated alpha level (0.05). Conclusions: HIV programs need to explore and address barriers to HIV partner testing services to avoid over-testing and maximize HIV case identification (thus, improving HIV testing positivity yield).

HIV index testing services in urban Lusaka: a review of medical records

Background: As the proportions of people living with HIV (PLHIV) who do not know their HIV infection status decrease, reaching the remaining few who are asymptomatic and not in contact with the health care system becomes a critical challenge. Therefore, reaching the first 90 of the UNAIDS 90-90-90 targets will require effective and efficient HIV testing approaches. The number of PLHIV who know their HIV status and who receive antiretroviral therapy could increase by the expansion of index testing services. Methods: This project was a retrospective study looking at medical records of HIV positive clients who were elicited for index testing between October and December 2019. It was conducted in three high volume health facilities in Matero Urban sub-district 3 in Lusaka, Zambia. Results: The HIV test outcomes for index contacts were as follows: 452 index contacts (53.5%) tested HIV negative, 113 index contacts (13.4%) tested HIV positive, 108 index contacts (12.8%) were known HIV positive, and 172 index contacts (20.4%) were not yet tested for HIV. Of the 113 contacts who tested HIV positive, 90 index contacts started anti-retroviral therapy within 7 days (79.6%). The total number of 845 contacts were elicited from 604 index clients, giving a low elicitation ratio of 1:1.4. There was not much difference between gender for elicited contacts (423 men and 422 women). A total number of 565 index contacts were eligible for HIV test. 113 of them tested HIV positive, representing a positivity yield of 20%. Pearson Chi-Square test value was 0.498 and the p value was 0.481. This result is not significant since p value (0.481) is greater than the designated alpha level (0.05). Conclusions: HIV programs need to explore and address barriers to HIV partner testing services to maximize HIV case identification.

HIV index partner testing services in urban Lusaka: a retrospective review of medical records

Background: As the proportions of people living with HIV (PLHIV) who do not know their HIV infection status decrease, reaching the remaining few who are asymptomatic and not in contact with the health care system becomes a critical challenge. Therefore, reaching the first 90 of the UNAIDS 90-90-90 targets will require effective and efficient HIV testing approaches. The number of PLHIV who know their HIV status and who receive antiretroviral therapy could increase by the expansion of index testing services. Methods: This project was a retrospective study looking at medical records of HIV positive clients who were elicited for index testing between October and December 2019. It was conducted in three high volume health facilities in Matero Urban sub-district 3 in Lusaka, Zambia. Results: The HIV test outcomes for index contacts were as follows: 452 index contacts (53.5%) tested HIV negative, 113 index contacts (13.4%) tested HIV positive, 108 index contacts (12.8%) were known HIV positive, and 172 index contacts (20.4%) were not yet tested for HIV. Of the 113 contacts who tested HIV positive, 90 index contacts started anti-retroviral therapy within 7 days (79.6%). The total number of 845 contacts were elicited from 604 index clients, giving a low elicitation ratio of 1:1.4. There was not much difference between gender for elicited contacts (423 men and 422 women). A total number of 565 index contacts were eligible for HIV test. 113 of them tested HIV positive, representing a positivity yield of 20%. Pearson Chi-Square test value was 6.376 and the p value was 0.012. This result is statistically significant since p value (0.481) is smaller than the designated alpha level (0.05). Conclusions: HIV programs need to explore and address barriers to HIV partner testing services to avoid over-testing and maximize HIV case identification (thus, improving HIV testing positivity yield).

"It is always better for a man to know his HIV status" - A qualitative study exploring the context, barriers and facilitators of HIV testing among men in Nairobi, Kenya

HIV testing services are an important component of HIV program and provide an entry point for clinical care for persons newly diagnosed with HIV. Although uptake of HIV testing has increased in Kenya, men are still less likely than women to get tested and access services. There is, however, limited understanding of the context, barriers and facilitators of HIV testing among men in the country. Data are from in-depth interviews with 30 men living with HIV and 8 HIV testing counsellors that were conducted to gain insights on motivations and drivers for HIV testing among men in the city of Nairobi. Men were identified retroactively by examining clinical CD4 registers on early and late diagnosis (e.g. CD4 of ≥500 cells/mm, early diagnosis and <500 cells/mm, late diagnosis). Analysis involved identifying broad themes and generating descriptive codes and categories. Timing for early testing is linked with strong social support systems and agency to test, while cost of testing, choice of facility to test and weak social support systems (especially poor inter-partner relations) resulted in late testing. Minimal discussions occurred prior to testing and whenever there was dialogue it happened with partners or other close relatives. Interrelated barriers at individual, health-care system, and interpersonal levels hindered access to testing services. Specifically, barriers to testing included perceived providers attitudes, facility location and set up, wait time/inconvenient clinic times, low perception of risk, limited HIV knowled ge, stigma, discrimination and fear of having a test. High risk perception, severe illness, awareness of partner's status, confidentiality, quality of services and supplies, flexible/extended opening hours, and pre-and post-test counselling were facilitators. Experiences between early and late testers overlapped though there were minor differences. In order to achieve the desired impact nationally and to attain the 90-90-90 targets, multiple interventions addressing both barriers and facilitators to testing are needed to increase uptake of testing and to link the positive to care.

Barriers to HIV testing uptake among men in sub-Saharan Africa: a scoping review

Introduction: HIV testing among men remains low globally and in sub-Saharan Africa (SSA) in particular, when compared with their female counterparts. The aim of this study was to synthesise evidence on barriers to HIV testing among men in SSA using a scoping review method.Methods: A scoping review was conducted, guided by Arksey and O'Malley's framework. A search was made in PubMed, American Doctoral Dissertations via EBSCOhost, Union Catalogue of Theses and Dissertations and SA ePublications via SABINET Online and World Cat Dissertations, Theses via OCLC and Google Scholar. The PRISMA (preferred reporting items for systematic reviews and meta-analyses) chart was used to document the review process. The PRISMA extension for scoping reviews - PRISMA-ScR: checklist and explanation - was also used. The mixed method appraisal tool version 2018 was used to determine the methodological quality of the included studies. Thematic analyses were conducted using NVivo version 11.Results: Key barriers to HIV testing among men in SSA were knowledge of HIV, fear of testing positive for HIV, stigma associated with HIV, healthcare providers' services, confidentiality, and clinic setting.Conclusion: Structural and individual factors present barriers to HIV testing uptake among men in SSA. Community and home-based initiatives have the potential to improve the uptake of HIV testing among men in SSA, considering the confidentiality concerns posed by clinic settings.

Prevention of mother-to-child transmission (PMTCT) of HIV: a review of the achievements and challenges in Burkina-Faso

BACKGROUND

Burkina-Faso's HIV/AIDS program is one of the most successful in Africa, with a declining HIV prevalence and treatment outcomes that rival those of developed countries. Prevention of mother-to-child transmission (PMTCT) guidelines in Burkina-Faso, initiated in the year 2000, were revised in 2004, 2006 and 2010. The guideline document has since undergone several stages of improvement, largely based on recommendations from WHO, with adaptations by local experts in the field. Option B+ adopted since August 2014 in Burkina-Faso has enabled maintenance of mothers on longer treatment and increasing their survival and that of their children. Through this review, we describe the achievements and challenges of HIV PMTCT programs in Burkina-Faso.

AIMS OF STUDY

This study had the following objectives: 1) describing the historical perspective of PMTCT implementation in Burkina-Faso; 2) presenting the effectiveness of interventions at improving PMTCT service delivery and promoting retention of mothers and babies in care; and 3) determining the impact of male partner involvement on PMTCT in Burkina-Faso.

METHODOLOGY

A literature search was conducted in PubMed and Google. Search terms included the following keywords: "HIV testing"; "prevention"; "mother"; "child"; "male partner"; "counseling"; "involvement"; "participation"; and the grouped terms "PMTCT and partners"; "VCT"; "barriers and/or factors"; "Male involvement in PMTCT"; and "Burkina-Faso". Data collection took place from May to October 2015. The search was limited to articles published between January 2002 and December 2015. UNICEF and UNAIDS web sites were also used to find relevant abstracts and documents.

RESULTS

Studies have revealed that with PMTCT, HIV transmission rate moved from 10.4% in 2006 to 0% in 2015. The PMTCT program remains the best way to care for HIV-infected pregnant women and their babies. The current PMTCT policy is based on evidence that male partner involvement is associated with women's completion of PMTCT.

CONCLUSION

This study shows that the reduction in mother to child transmission of HIV in Burkina-Faso over the years is mainly due to the improvement of PMTCT programs. Efforts still need to be made about the involvement of male partners.

Stigma: A biocultural proposal for integrating evolutionary and political-economic approaches

OBJECTIVES

Stigma-the process by which people become socially discredited because they hold a characteristic that is classified as unacceptable or undesirable-has barely been considered in biocultural analyses. Yet, it provides an acute point of articulation for evolutionary and political-economic perspectives on human variation, including the biocultural production of health disparities. To explain the theoretical integration of the two perspectives to stigma, we first lay out some operationalizable definitions of stigma, and review feasible methods to capture them in the field. We then test the roles of predictors suggested from evolutionary (respondent's level of disgust, fear of contagion) and political-economic (respondent's perceived social standing and negative social labeling of those who violate hygiene norms) theories of stigma.

METHODS

We used survey, interview, and behavioral report data from a study of hygiene behaviors at four local community sites in Guatemala, Fiji, New Zealand, and the United States (N = 300). We applied a hierarchical GLMM design that treats site as a random effect.

RESULTS

The independent influences of both variable sets are evident in publicly visible forms of reported hygiene behaviors, specifically the exhibition of clean bodies, clothes, and homes.

CONCLUSION

We propose that the study of stigma provides a productive operationalizable space to engage the promise of the biocultural synthesis to integrate evolutionary and political-economic models of health and human variation.

The gendered experience of HIV testing: factors associated with prior testing differ among men and women in rural Tanzania

HIV testing remains below UNAIDS 90–90–90 goals in sub-Saharan Africa. The aim of this study was to understand gender-specific factors related to HIV testing in Kisarawe, Tanzania. Informed by Social Action Theory, we analyzed cross-sectional data from a population-based random sample using bivariate and multivariate logistic regression to identify the contextual, behavioral, and interpersonal factors associated with prior HIV testing – specifically, any prior testing and testing within the past year. Of 644 participants, 63.1% of men and 85.5% of women reported ever testing for HIV. Younger men and women (aged 18–25 years) had significantly lower odds of prior HIV testing compared with older participants. For men, low levels of anticipated stigma and having ever talked about HIV were both positively associated with any prior testing. Men who knew if a sexual partner had received an HIV test had almost three times the odds of receiving a recent HIV test compared to men with no knowledge of their partners’ testing status (aOR = 2.96, 95% CI: 1.22–7.17, p = 0.01). For women, knowing someone who is HIV-positive was associated with increased odds of any prior testing (aOR = 2.74, 95% CI: 1.24–6.07, p = 0.01). Gender-specific, proactive interventions are needed to increase testing uptake, especially for young people and men.

Mainstreaming gender into global health programming to improve women's health

In this paper, a case is made for mainstreaming gender into global women's health programming and policies. The potential implications of conflating "gender" with "women'" in the design and evaluation of women's health programming are first considered. HIV/AIDS case studies are then used to depict examples of (a) where gender has been well integrated and (b) where policies fall short of gender mainstreaming. Finally, practical approaches to mainstream gender in a meaningful way into the design and evaluation of women's health programming and policies are provided for practitioners and researchers.

Barriers to achieving the first 90%: gender norms and HIV testing among men in the Democratic Republic of the Congo

Gender inequality and gender norms are key social drivers of the HIV epidemic through their influences on sexual relationships, behavior, and risk taking. However, few empirical studies have measured the influence of gender norms on HIV sexual-risk behaviors and HIV testing among men in sub-Saharan Africa. We analyzed cross-sectional, survey data from 399 sexually active men (ages 18-39) in Democratic Republic of the Congo to examine the relationship between the men's support for inequitable gender norms and their HIV-risk behaviors. Logistic regression analyses revealed that moderate and strong levels of support for inequitable gender norms were significantly associated with never having been tested for HIV (AOR = 2.92, p < .05 and AOR = 3.41, p < .01, for moderate and strong support, respectively). Our findings indicate that changing the prevailing gender norms should be prioritized in HIV-prevention efforts that aim to increase counseling and testing for men.

Outcomes and Experiences of Men and Women with Partner Notification for HIV Testing in Tanzania: Results from a Mixed Method Study

A growing evidence base supports expansion of partner notification in HIV testing services (HTS) in sub-Saharan Africa. In 2015, a cross-sectional study was conducted in Njombe region, Tanzania, to evaluate partner notification within facility-based HTS. Men and women newly diagnosed with HIV were enrolled as index clients and asked to list current or past sexual partners for referral to HTS. Successful partner referral was 2.5 times more likely among married compared to unmarried index clients and 2.2 times more likely among male compared to female index clients. In qualitative analysis, male as well as female index clients mentioned difficulties notifying past or casual partners, and noted disease symptoms as a motivating factor for HIV testing. Female index clients mentioned gender-specific challenges to successful referral. Women may need additional support to overcome challenges in the partner notification process. In addition to reducing barriers to partner notification specific to women, a programmatic emphasis on social strengths of males in successfully referring partners should be considered.

Uptake of HIV testing in Burkina Faso: an assessment of individual and community-level determinants

Background

Previous studies have highlighted a range of individual determinants associated with HIV testing but few have assessed the role of contextual factors. The objective of this paper is to examine the influence of both individual and community-level determinants of HIV testing uptake in Burkina Faso.

Methods

Using nationally representative cross-sectional data from the 2010 Demographic and Health Survey, the determinants of lifetime HIV testing were examined for sexually active women (n = 14,656) and men (n = 5680) using modified Poisson regression models.

Results

One third of women (36%; 95% Confidence Interval (CI): 33–37%) reported having ever been tested for HIV compared to a quarter of men (26%; 95% CI: 24–27%). For both genders, age, education, religious affiliation, household wealth, employment, media exposure, sexual behaviors, and HIV knowledge were associated with HIV testing. After adjustment, women living in communities where the following characteristics were higher than the median were more likely to report uptake of HIV testing: knowledge of where to access testing (Prevalence Ratio [PR] = 1.41; 95% CI: 1.34–1.48), willing to buy food from an infected vendor (PR = 2.06; 95% CI: 1.31–3.24), highest wealth quintiles (PR = 1.18; 95% CI: 1.10–1.27), not working year-round (PR = 0.90; 95% CI: 0.84–0.96), and high media exposure (PR = 1.11; 95% CI: 1.03–1.19). Men living in communities where the proportion of respondents were more educated (PR = 1.23; 95% CI: 1.07–1.41) than the median were more likely to be tested.

Conclusions

This study shed light on potential mechanisms through which HIV testing could be increased in Burkina Faso. Both individual and contextual factors should be considered to design effective strategies for scaling-up HIV testing.

Assessing factors associated with HIV testing among adolescents in Malawi

Despite being at high risk of HIV/AIDS, most young people do not know their HIV status. Using survey data (n = 2428) and applying multilevel models, this paper assesses factors associated with HIV testing among adolescents in Northern Malawi. The results show that among both boys (OR = 0.39) and girls (OR = 0.47), orphan status is associated with low likelihood of HIV testing. Correct knowledge about HIV/AIDS (OR = 2.55) and having secondary education (OR = 3.24) are associated with HIV testing among boys and girls, respectively. At the household level, living in a household whose head has secondary or higher education is positively associated with testing for boys (OR = 2.63), while residing together with biological siblings predicts higher odds of testing (OR = 2.67) for girls. Notably, orphaned girls' disadvantage regarding HIV testing loses significance when residential arrangement is controlled. At the community level, having HIV testing facility (OR = 2.70) or post-test club (OR = 1.40) is positively associated with HIV testing for boys, while girls from areas where religious leaders hold judgmental views about HIV/AIDS are less likely (OR = 0.45) to test. These findings suggest that efforts to scale up HIV testing among youth could benefit greatly from an understanding of how individual and community factors operate to influence adolescents to know their sero-status.

Why do marital partners of people living with HIV not test for HIV? A qualitative study in Lusaka, Zambia

BACKGROUND

Knowledge of HIV status is crucial for HIV prevention and management in marital relationships. Yet some marital partners of people living with HIV decline HIV testing despite knowing the HIV-positive status of their partners. To date, little research has explored the reasons for this.

METHODS

An exploratory qualitative study was undertaken in Lusaka, Zambia, between March 2010 and September 2011, nested within a larger ethnographic study. In-depth interviews were held with individuals who knew the HIV-positive status of their marital partners but never sought HIV testing (n = 30) and HIV service providers of a public sector clinic (n = 10). A focus group discussion was also conducted with eight (8) lay HIV counsellors. Data was transcribed, coded and managed using ATLAS.ti and analysed using latent content analysis.

RESULTS

The overarching barrier to uptake of HIV testing was study participants' perception of their physical health, reinforced by uptake of herbal remedies and conventional non-HIV medication to mitigate perceived HIV-related symptoms. They indicated willingness to test for HIV if they noticed a decline in physical health and other alternative forms of care became ineffective. Also, some study participants viewed themselves as already infected with HIV on account of the HIV-positive status of their marital partners, with some opting for faith healing to get 'cured'. Other barriers were the perceived psychological burden of living with HIV, modulated by lay belief that knowledge of HIV-positive status led to rapid physical deterioration of health. Perceived inability to sustain uptake of life-long treatment - influenced by a negative attitude towards treatment - further undermined uptake of HIV testing. Self-stigma, which manifested itself through fear of blame and a need to maintain moral credibility in marital relationships, also undermined uptake of HIV testing.

CONCLUSIONS

Improving uptake of HIV testing requires a multi-pronged approach that addresses self-stigma, lay risk perceptions, negative treatment and health beliefs and the perceived psychological burden of living with HIV. Strengthening couple HIV testing services, including addressing conflict and addressing gendered power relationships are also warranted to facilitate joint knowledge, acceptance and management of HIV status in marital relationships.

Factors Affecting the Uptake of HIV Testing among Men: A Mixed-Methods Study in Rural Burkina Faso

Background

This study aimed to explore factors shaping the decision to undergo Human Immunodeficiency Virus (HIV) testing among men in rural Burkina Faso.

Methods

The study took place in 2009 in the Nouna Health District and adopted a triangulation mixed methods design. The quantitative component relied on data collected through a structured survey on a representative sample of 1130 households. The qualitative component relied on 38 in-depth interviews, with men purposely selected to represent variation in testing decision, age, and place of residence. A two-part model was conducted, with two distinct outcome variables, i.e. “being offered an HIV test” and “having done an HIV test”. The qualitative data analysis relied on inductive coding conducted by three independent analysts.

Result

Of the 937 men, 357 had been offered an HIV test and 97 had taken the test. Younger age, household wealth, living in a village under demographic surveillance, and knowing that HIV testing is available at primary health facilities were all positively associated with the probability of being offered an HIV test. Household wealth and literacy were found to be positively associated, and distance was found to be negatively associated with the probability of having taken an HIV test. Qualitative findings indicated that the limited uptake of HIV testing was linked to poor knowledge on service availability and to low risk perceptions.

Conclusion

With only 10% of the total sample ever having tested for HIV, our study confirmed that male HIV testing remains unacceptably low in Sub-Saharan Africa. This results from a combination of health system factors, indicating general barriers to access, and motivational factors, such as one’s own knowledge of service availability and risk perceptions. Our findings suggested that using antenatal care and curative services as the exclusive entry points into HIV testing may not be sufficient to reach large portions of the male population. Thus, additional strategies are urgently needed to increase service uptake.

Factors associated with HIV voluntary disclosure of people living with HIV to their steady sexual partner in the Democratic Republic of the Congo: results from a community-based participatory research

Introduction

HIV disclosure to a steady sexual partner (SSP) is important both in preventing HIV transmission and improving the quality of life of people living with HIV (PLHIV). Its determinants have been poorly investigated in the Democratic Republic of the Congo. The study objective was to determine factors independently associated with voluntary disclosure to one's SSP in PLHIV receiving services from a Congolese community-based organization (CBO).

Methods

A community-based participatory research was performed and 300 PLHIV were interviewed by members of the CBO, using a standardized questionnaire. A multivariate logistic regression was used to determine the variables independently associated with disclosure.

Results

In this sample, 79 of the 127 participants (62%) included in the analysis declared having voluntarily disclosed their serostatus to their SSP. Declaring to be in a relationship (Odds Ratio (95% Confidence Interval): 4.2 (1.4-12.6)), having tested for HIV because of symptoms (2.5 (1.0-6.4)), having taken the test on one's own initiative (3.2 (1.3-8.0)), having felt sympathy and indifference from people when disclosing (6.0 (1.4-26.9) and 5.0 (1.1-22.8), respectively) as well as having a higher score of the “regular discussion about daily life with HIV” index (1.7 (1.1-2.5)) were significantly associated with disclosure to one's SSP.

Conclusion

Several individual and contextual factors were associated with voluntary disclosure to SSP in this study, highlighting the complex nature of the disclosure process. Interventions encouraging disclosure should be designed so as to adapt to one's personal life with HIV as well as psychosocial environment.

[Disclosing HIV status: the experience of PLHIV after 10 years of ARV treatment in Senegal]

Rates of HIV status disclosure observed in Africa, especially to partners, are too low for an optimal implementation of preventive strategies. Access to antiretroviral drugs appears to have facilitated disclosure in the short term, but knowledge is insufficient about long-term practices. A study held with 185 people living with HIV (PLHIV) examined factors associated with disclosure in general and with partners over 10 years of antiretroviral treatment in Dakar. Two third of PLHIV disclosed their status to at least one person, and 56% with their partners. The main results concern factors associated with disclosure to partners (having a child, knowing one's partner status) which are different from factors associated to disclosure in general (duration of ART treatment, secondary or higher education level, being a member of an association). After ten years, 44% of people still living in couple has not disclosed (no significant differences by sex and marital regime). These results invite to regularly offer counselling to PLHIV during follow-up.

Masculinity, social context and HIV testing: an ethnographic study of men in Busia district, rural eastern Uganda

Background

Uptake of HIV testing by men remains low in high prevalence settings in many parts of Africa. By focusing on masculinity, this study explores the social context and relations that shape men’s access to HIV testing in Mam-Kiror, Busia district, rural eastern Uganda.

Methods

From 2009–2010 in-depth interviews were undertaken with 26 men: nine being treated for HIV, eight who had tested but dropped out of treatment, six not tested but who suspected HIV infection and three with other health problems unrelated to HIV. These data were complemented by participant observation. Thematic analysis was undertaken.

Results

There were two main categories of masculinity in Mam-Kiror, one based on ‘reputation’ and the other on ‘respectability’, although some of their ideals overlapped. The different forms of masculine esteem led to different motives for HIV testing. Men positioned HIV testing as a social process understood within the social context and relationships men engaged in rather than an entirely self-determined enterprise. Wives’ inferior power meant that they had less influence on men’s testing compared to friends and work colleagues who discussed frankly HIV risk and testing. Couple testing exposed men’s extra-marital relationships, threatening masculine esteem. The fear to undermine opportunities for sex in the context of competition for partners was a barrier to testing by men. The construction of men as resilient meant that they delayed to admit to problems and seek testing. However, the respectable masculine ideal to fulfil responsibilities and obligations to family was a strong motivator to seeking an HIV test and treatment by men.

Conclusion

The two main forms of masculine ideals prevailing in Mam-Kiror in Busia led men to have different motives for HIV testing. Reputational masculinity was largely inconsistent with the requirements of couple testing, community outreach testing and the organisation of testing services, discouraging men from testing. Conversely, concern to perform one’s family roles as a respectable man meant accessing treatment to extend one’s life, which encouraged men to test. HIV support agencies should reflect on how various testing options might marginalise men from seeking testing services and address the barriers that hinder access.

Experiences of stigma, discrimination, care and support among people living with HIV: a four country study

While it is widely agreed that HIV-related stigma may impede access to treatment and support, there is little evidence describing who is most likely to experience different forms of stigma and discrimination and how these affect disclosure and access to care. This study examined experiences of interpersonal discrimination, internalized stigma, and discrimination at health care facilities among HIV-positive adults aged 18 years and older utilizing health facilities in four countries in Sub-Saharan Africa (N = 536). Prevalence of interpersonal discrimination across all countries was 34.6 %, with women significantly more likely to experience interpersonal discrimination than men. Prevalences of internalized stigma varied across countries, ranging from 9.6 % (Malawi) to 45.0 % (Burkina Faso). Prevalence of health care discrimination was 10.4 % across all countries. In multiple regression analyses, we found positive, significant, and independent associations between disclosure and interpersonal discrimination and disclosure and support group utilization, and positive associations between both internalized stigma and health care discrimination and referral for medications.

A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in Sub-Saharan Africa

BACKGROUND

Despite Sub-Saharan Africa (SSA) being the epicenter of the HIV epidemic, uptake of HIV testing is not optimal. While qualitative studies have been undertaken to investigate factors influencing uptake of HIV testing, systematic reviews to provide a more comprehensive understanding are lacking.

METHODS

Using Noblit and Hare's meta-ethnography method, we synthesised published qualitative research to understand factors enabling and deterring uptake of HIV testing in SSA. We identified 5,686 citations out of which 56 were selected for full text review and synthesised 42 papers from 13 countries using Malpass' notion of first-, second-, and third-order constructs.

RESULTS

The predominant factors enabling uptake of HIV testing are deterioration of physical health and/or death of sexual partner or child. The roll-out of various HIV testing initiatives such as 'opt-out' provider-initiated HIV testing and mobile HIV testing has improved uptake of HIV testing by being conveniently available and attenuating fear of HIV-related stigma and financial costs. Other enabling factors are availability of treatment and social network influence and support. Major barriers to uptake of HIV testing comprise perceived low risk of HIV infection, perceived health workers' inability to maintain confidentiality and fear of HIV-related stigma. While the increasingly wider availability of life-saving treatment in SSA is an incentive to test, the perceived psychological burden of living with HIV inhibits uptake of HIV testing. Other barriers are direct and indirect financial costs of accessing HIV testing, and gender inequality which undermines women's decision making autonomy about HIV testing. Despite differences across SSA, the findings suggest comparable factors influencing HIV testing.

CONCLUSIONS

Improving uptake of HIV testing requires addressing perception of low risk of HIV infection and perceived inability to live with HIV. There is also a need to continue addressing HIV-related stigma, which is intricately linked to individual economic support. Building confidence in the health system through improving delivery of health care and scaling up HIV testing strategies that attenuate social and economic costs of seeking HIV testing could also contribute towards increasing uptake of HIV testing in SSA.

HIV testing and care in Burkina Faso, Kenya, Malawi and Uganda: ethics on the ground

BACKGROUND

The ethical discourse about HIV testing has undergone a profound transformation in recent years. The greater availability of antiretroviral therapy (ART) has led to a global scaling up of HIV testing and counseling as a gateway to prevention, treatment and care. In response, critics raised important ethical questions, including: How do different testing policies and practices undermine or strengthen informed consent and medical confidentiality? How well do different modalities of testing provide benefits that outweigh risks of harm? To what degree do current testing policies and programs provide equitable access to HIV services? And finally, what lessons have been learned from the field about how to improve the delivery of HIV services to achieve public health objectives and protections for human rights? This article reviews the empirical evidence that has emerged to answer these questions, from four sub-Saharan African countries, namely: Burkina Faso, Kenya, Malawi and Uganda.

DISCUSSION

Expanding access to treatment and prevention in these four countries has made the biomedical benefits of HIV testing increasingly clear. But serious challenges remain with regard to protecting human rights, informed consent and ensuring linkages to care. Policy makers and practitioners are grappling with difficult ethical issues, including how to protect confidentiality, how to strengthen linkages to care, and how to provide equitable access to services, especially for most at risk populations, including men who have sex with men.

SUMMARY

The most salient policy questions about HIV testing in these countries no longer address whether to scale up routine PITC (and other strategies), but how. Instead, individuals, health care providers and policy makers are struggling with a host of difficult ethical questions about how to protect rights, maximize benefits, and mitigate risks in the face of resource scarcity.

How a masculine work ethic and economic circumstances affect uptake of HIV treatment: experiences of men from an artisanal gold mining community in rural eastern Uganda

BACKGROUND

Current data from Uganda indicate that, compared to women, men are under-represented in HIV treatment, seek treatment later and have a higher mortality while on antiretroviral therapy (ART). By focusing on a masculine work ethic as one of the most predominant expressions of masculinity, this study explores why for some men HIV treatment enhances their masculinity while for others it undermines masculine work identity, leading them to discontinue the treatment.

METHODS

Participant observation and 26 in-depth interviews with men were conducted in a gold mining village in Eastern Uganda between August 2009 and August 2010. Interviewees included men who were taking HIV treatment, who had discontinued treatment, who suspected HIV infection but had not sought testing, or who had other symptoms unrelated to HIV infection.

RESULTS

Many participants reported spending large proportions of their income, alleviating symptoms prior to confirming their HIV infection. This seriously undermined their sense of masculinity gained from providing for their families. Disclosing HIV diagnosis and treatment to employers and work colleagues could reduce job offers and/or collaborative work, as colleagues feared working with "ill" people. Drug side-effects affected work, leading some men to discontinue the treatment. Despite being on ART, some men believed their health remained fragile, leading them to opt out of hard work, contradicting their reputation as hard workers. However, some men on treatment talked about "resurrecting" due to ART and linked their current abilities to work again to good adherence. For some men, it was work colleagues who suggested testing and treatment-seeking following symptoms.

CONCLUSIONS

The central role of a work ethic in expressing masculinity can both encourage and discourage men's treatment-seeking for AIDS. HIV testing and treatment may be sought in order to improve health and get back to work, thereby in the process regaining one's masculine reputation as a hard worker and provider for one's family. However, disclosure can affect opportunities for work and drug side-effects disrupt one's ability to labour, undermining the sense of masculinity gained from work. HIV support organizations need to recognize how economic and gender concerns impact on treatment decisions and help men deal with work-related fears.

The ambivalence of stigma and the double-edged sword of HIV/AIDS intervention in Burkina Faso

This article analyses the causes of HIV stigmatisation in Burkina Faso as perceived by people living with HIV/AIDS (PLHIV) and people working in AIDS-related Community Based Organisations (CBOs). Stigmatisation continues to be a pressing issue when dealing with HIV/AIDS in Sub-Saharan Africa. The article is based on direct observation of HIV-related practices within 20 CBOs in Burkina Faso, as well as semi-structured interviews or focus group discussions with 72 PLHIV and 90 professionals and volunteers working in CBOs. PLHIV were chosen by convenience sampling among the persons who accessed CBO services and were interviewed about their life quality and experience relating to HIV. Professionals and volunteers were interviewed about their strategies, their achievements, and the problems they encountered. The research was conducted in the course of three months fieldwork between September and November 2009. Our principal findings show, firstly, that moral or social stigmatisation does not in any simple way derive from fear, ignorance or inaccurate beliefs but that it is also established and continually reinforced by official campaigns addressing HIV/AIDS. Secondly, we show that stigmatisation is a socially complex and ambiguous process. Based on these empirical findings we conclude that HIV/AIDS need no longer be approached in AIDS intervention as a sexually acquired and fatal disease. When reliable access to antiretroviral drugs is in place, AIDS becomes a chronic condition with which one can live for many years, and this makes it easier to address HIV and moral or social stigmatisation by downplaying the current focus upon sexuality and morality.

Women's views on consent, counseling and confidentiality in PMTCT: a mixed-methods study in four African countries

BACKGROUND

Ambitious UN goals to reduce the mother-to-child transmission of HIV have not been met in much of Sub-Saharan Africa. This paper focuses on the quality of information provision and counseling and disclosure patterns in Burkina Faso, Kenya, Malawi and Uganda to identify how services can be improved to enable better PMTCT outcomes.

METHODS

Our mixed-methods study draws on data obtained through: (1) the MATCH (Multi-country African Testing and Counseling for HIV) study's main survey, conducted in 2008-09 among clients (N = 408) and providers at health facilities offering HIV Testing and Counseling (HTC) services; 2) semi-structured interviews with a sub-set of 63 HIV-positive women on their experiences of stigma, disclosure, post-test counseling and access to follow-up psycho-social support; (3) in-depth interviews with key informants and PMTCT healthcare workers; and (4) document study of national PMTCT policies and guidelines. We quantitatively examined differences in the quality of counseling by country and by HIV status using Fisher's exact tests.

RESULTS

The majority of pregnant women attending antenatal care (80-90%) report that they were explained the meaning of the tests, explained how HIV can be transmitted, given advice on prevention, encouraged to refer their partners for testing, and given time to ask questions. Our qualitative findings reveal that some women found testing regimes to be coercive, while disclosure remains highly problematic. 79% of HIV-positive pregnant women reported that they generally keep their status secret; only 37% had disclosed to their husband.

CONCLUSION

To achieve better PMTCT outcomes, the strategy of testing women in antenatal care (perceived as an exclusively female domain) when they are already pregnant needs to be rethought. When scaling up HIV testing programs, it is particularly important that issues of partner disclosure are taken seriously.

Combining qualitative and quantitative evidence to determine factors leading to late presentation for antiretroviral therapy in Malawi

Background

Treatment seeking delays among people living with HIV have adverse consequences for outcome. Gender differences in treatment outcomes have been observed in sub-Saharan Africa.

Objective

To better understand antiretroviral treatment (ART) seeking behaviour in HIV-infected adults in rural Malawi.

Methods

Qualitative interviews with male and female participants in an ART cohort study at a treatment site in rural northern Malawi triangulated with analysis of baseline clinical and demographic data for 365 individuals attending sequentially for ART screening between January 2008 and September 2009.

Results

43% of the cohort presented with late stage HIV disease classified as WHO stage 3/4. Respondents reported that women's frequency of testing, health awareness and commitment to children led to earlier ART uptake and that men's commitment to wider social networks of influence, masculine ideals of strength, and success with sexual and marital partners led them to refuse treatment until they were sick. Quantitative analysis of the screening cohort provided supporting evidence for these expressed views. Overall, male gender (adjusted OR 2.3, 95% CI1.3–3.9) and never being married (adjusted OR 4.1, 95% CI1.5–11.5) were risk factors for late presentation, whereas having ≥3 dependent children was associated with earlier presentation (adjusted OR 0.31, 95% CI0.15–0.63),compared to those with no dependent children.

Conclusion

Gender-specific barriers and facilitators operate throughout the whole process of seeking care. Further efforts to enrol men into care earlier should focus on the masculine characteristics that they value, and the risks to these of severe health decline. Our results emphasise the value of exploring as well as identifying behavioural correlates of late presentation.

When masculinity interferes with women's treatment of HIV infection: a qualitative study about adherence to antiretroviral therapy in Zimbabwe

Background

Social constructions of masculinity have been shown to serve as an obstacle to men's access and adherence to antiretroviral therapies (ART). In the light of women's relative lack of power in many aspects of interpersonal relationships with men in many African settings, our objective is to explore how male denial of HIV/AIDS impacts on their female partners' ability to access and adhere to ART.

Methods

We conducted a qualitative case study involving thematic analysis of 37 individual interviews and five focus groups with a total of 53 male and female antiretroviral drug users and 25 healthcare providers in rural eastern Zimbabwe.

Results

Rooted in hegemonic notions of masculinity, men saw HIV/AIDS as a threat to their manhood and dignity and exhibited a profound fear of the disease. In the process of denying and avoiding their association with AIDS, many men undermine their wives' efforts to access and adhere to ART. Many women felt unable to disclose their HIV status to their husbands, forcing them to take their medication in secret, and act without a supportive treatment partner, which is widely accepted to be vitally important for adherence success. Some husbands, when discovering that their wives are on ART, deny them permission to take the drugs, or indeed steal the drugs for their own treatment. Men's avoidance of HIV also leave many HIV-positive women feeling vulnerable to re-infection as their husbands, in an attempt to demonstrate their manhood, are believed to continue engaging in HIV-risky behaviours.

Conclusions

Hegemonic notions of masculinity can interfere with women's adherence to ART. It is important that those concerned with promoting effective treatment services recognise the gender and household dynamics that may prevent some women from successfully adhering to ART, and explore ways to work with both women and men to identify couples-based strategies to increase adherence to ART

Masculinity as a barrier to men's use of HIV services in Zimbabwe

BACKGROUND

A growing number of studies highlight men's disinclination to make use of HIV services. This suggests there are factors that prevent men from engaging with health services and an urgent need to unpack the forms of sociality that determine men's acceptance or rejection of HIV services.

METHODS

Drawing on the perspectives of 53 antiretroviral drug users and 25 healthcare providers, we examine qualitatively how local constructions of masculinity in rural Zimbabwe impact on men's use of HIV services.

RESULTS

Informants reported a clear and hegemonic notion of masculinity that required men to be and act in control, to have know-how, be strong, resilient, disease free, highly sexual and economically productive. However, such traits were in direct conflict with the 'good patient' persona who is expected to accept being HIV positive, take instructions from nurses and engage in health-enabling behaviours such as attending regular hospital visits and refraining from alcohol and unprotected extra-marital sex. This conflict between local understandings of manhood and biopolitical representations of 'a good patient' can provide a possible explanation to why so many men do not make use of HIV services in Zimbabwe. However, once men had been counselled and had the opportunity to reflect upon the impact of ART on their productivity and social value, it was possible for some to construct new and more ART-friendly versions of masculinity.

CONCLUSION

We urge HIV service providers to consider the obstacles that prevent many men from accessing their services and argue for community-based and driven initiatives that facilitate safe and supportive social spaces for men to openly discuss social constructions of masculinity as well as renegotiate more health-enabling masculinities.

Understanding the gender disparity in HIV infection across countries in sub-Saharan Africa: evidence from the Demographic and Health Surveys

Women in sub-Saharan Africa bear a disproportionate burden of human immunodeficiency virus (HIV) infections, which is exacerbated by their role in society and biological vulnerability. The specific objectives of this article are to (i) determine the extent of gender disparity in HIV infection; (ii) examine the role of HIV/acquired immune deficiency syndrome (AIDS) awareness and sexual behaviour factors on the gender disparity and (iii) establish how the gender disparity varies between individuals of different characteristics and across countries. The analysis involves multilevel logistic regression analysis applied to pooled Demographic and Health Surveys data from 20 countries in sub-Saharan Africa conducted during 2003-2008. The findings suggest that women in sub-Saharan Africa have on average a 60% higher risk of HIV infection than their male counterparts. The risk for women is 70% higher than their male counterparts of similar sexual behaviour, suggesting that the observed gender disparity cannot be attributed to sexual behaviour. The results suggest that the risk of HIV infection among women (compared to men) across countries in sub-Saharan Africa is further aggravated among those who are younger, in female-headed households, not in stable unions or marital partnerships or had an earlier sexual debut.

Advocating prevention over punishment: the risks of HIV criminalization in Burkina Faso

In 2004, parliamentarians from 12 countries in West and Central Africa created a template for legislation aimed at protecting the rights of people with HIV and stemming rising HIV infection rates by criminalizing HIV transmission. Since then, the template has been adopted as national law in 15 African countries, including Burkina Faso in 2008. The Burkina Faso law offers a number of protections for people with HIV, such as confidentiality of HIV test results, and holds the government accountable for providing health services for people with HIV and education about HIV in schools. However, other articles in the law, which criminalize HIV transmission and mandate disclosure of HIV status, may contribute to violations of the human rights of women and men with HIV. This article reviews the two cases brought in Burkina Faso under the 2008 HIV law to date, both against women, and explores the implications of specific elements of the legislation. It recommends that Burkina Faso use guidance provided by UNAIDS and the Southern Africa Development Community to repeal harmful articles in the HIV-specific legislation and implement the positive provisions. Prioritizing HIV prevention over punishment is the best way to respect the rights of people living with HIV and AIDS.