Rural Malawians’ Perceptions of HIV risk behaviors and their sociocultural context

A longitudinal qualitative evaluation of an economic and social empowerment intervention to reduce girls' vulnerability to HIV in rural Mozambique

PURPOSE

An intervention including business training and health education was implemented in Mozambique, where girls are at elevated risk for acquiring HIV. As part of a mixed-methods evaluation, we describe perceived effects of the intervention on girls' sexual behavior and school attendance.

METHODS

We conducted 49 in-depth interviews (IDIs) with girl intervention participants (ages 13-19), 24 IDIs with heads of girls' households, 36 IDIs with influential males identified by girls, and 12 focus group discussions with community members after the intervention ended and one year later.

RESULTS

Informants said the primary intervention benefit was realized when girls had money to stay in or return to school and/or to buy necessities for themselves and their households-reducing their need for transactional or intergenerational sex. However, some girls did not make a profit and some businesses were not sustainable. Sometimes the intervention appeared to be implemented in a way to reinforce inequitable gender norms resulting in some girls feeling shame when they reengaged in risky sex after their businesses failed.

CONCLUSIONS

Earning money enabled girls to potentially reduce their vulnerability to HIV. We offer recommendations for future multi-sector interventions, including the need to address potential harms in programs serving vulnerable girls.

Quasi-experimental evaluation using confirmatory procedures: A case study of an economic and social empowerment intervention to reduce girls' vulnerability to HIV in rural Mozambique

PURPOSE

Our goal was to determine whether an economic and social empowerment intervention implemented in Zambézia Province, Mozambique reduced girls' vulnerability to HIV. We use this experience to discuss challenges of evaluating real-world interventions.

METHODS

Two rounds of data were collected from 885 girls, 13-19 years, for this clustered, non-equivalent (two-stage) cohort trial. We used multi-level exact matching and difference-in-differences estimation to estimate intervention effects on two outcomes: girls' knowledge of gender-based violence and school attendance.

RESULTS

Estimates of two outcomes analysed indicated no statistically significant intervention effects. Preliminary analysis of data from the intervention group revealed this study was unable to obtain accurate measures for five outcomes related to HIV vulnerability.

CONCLUSIONS

Although our study did not find evidence of impact on the a priori selected outcomes, we report on our experience implementing this robust methodologic design and describe how the challenges encountered in this program setting affected our ability to attain results. We recommend prospective evaluation designs with random allocation be accommodated early during planning. When not possible, quasi-experimental studies should collect data from large samples. To reduce measurement bias, biological endpoints such sexually transmitted infections should serve as primary outcomes for programs intending to reduce sexual behaviors.

Exploring HIV risks, testing and prevention among sub-Saharan African community members in Australia

Background

Significant health disparities persist regarding new and late Human Immunodeficiency Virus (HIV) diagnoses among sub-Saharan African (SSA) communities in Australia. Personal/cultural beliefs and practices influence HIV (risk, prevention, testing) within Australia and during visits to home countries.

Method

A community forum was conducted involving 23 male and female adult African community workers, members and leaders, and health workers; facilitated by cultural workers and an experienced clinician/researcher. The forum comprised small/large group discussions regarding HIV risk/prevention (responses transcribed verbatim; utilising thematic analysis).

Results

Stigma, denial, social norms, tradition and culture permeated perceptions/beliefs regarding HIV testing, prevention and transmission among African Australians, particularly regarding return travel to home countries.

Conclusions

International travel as a risk factor for HIV acquisition requires further examination, as does the role of the doctor in HIV testing and Pre-exposure Prophylaxis (PrEP). Further assessment of PrEP as an appropriate/feasible intervention is needed, with careful attention regarding negative community perceptions and potential impacts.

Participation and diffusion effects of a peer-intervention for HIV prevention among adults in rural Malawi

This paper examines whether a peer group intervention that reduced self-reported risky behaviors for rural adults in Malawi also had impacts on non-participants in the same communities. We randomly assigned two districts to the intervention and control conditions, and conducted surveys at baseline and 18 months post-intervention using unmatched independent random samples of intervention and control communities in 2003-2006. The six-session peer group intervention was offered to same-gender groups by trained volunteers. In this analysis, we divided the post-intervention sample into three exposure groups: 243 participants and 170 non-participants from the intervention district (total n = 415) and 413 control individuals. Controlling for demographics and participation, there were significant favorable diffusion effects on five partially overlapping behavioral outcomes: partner communication, ever used condoms, unprotected sex, recent HIV test, and a community HIV prevention index. Non-participants in the intervention district had more favorable outcomes on these behaviors than survey respondents in the control district. One behavioral outcome, community HIV prevention, showed both participation and diffusion effects. Participating in the intervention had a significant effect on six psychosocial outcomes: HIV knowledge (two measures), hope, condom attitudes, and self-efficacy for community HIV prevention and for safer sex; there were no diffusion effects. This pattern of results suggests that the behavioral changes promoted in the intervention spread to others in the same community, most likely through direct contact between participants and non-participants. These findings support the idea that diffusion of HIV-related behavior changes can occur for peer group interventions in communities, adding to the body of research supporting diffusion of innovations theory as a robust approach to accelerating change. If diffusion occurs, peer group intervention may be more cost-effective than previously realized. Wider implementation of peer group interventions can help meet the global goal of reducing new HIV infections.

Renegotiating cultural practices as a result of HIV in the eastern region of Malawi

A number of studies have shown that HIV awareness is very high among Malawians and yet infection rates are rising. Local cultural practices have been identified as contributing to this contradictory situation. Using data from 12 focus-group discussions collected in Balaka, Zomba, Machinga and Mangochi, the paper explores the reformulation of nine cultural practices as a preventive measure against HIV. The study reveals that cultural practices that involve sexual acts for completion are mediated through condoms and HIV tests. The study also shows that traditional herbs known for healing ailments are repurposed to symbolise sexual acts. We conclude that the idea of repurposing offers an avenue in which initiation and cleansing rites that involve sexual acts are replaced by other semiotics such as a traditional medicine called mtela. We also conclude that the modifications to cultural practices do not indicate complete abandonment of associated traditions, rather, they constitute the renegotiation of cultural practices and meanings associated with particular rites of passage. Lastly, we propose that a comprehensive prevention programme needs to be part of a wider national HIV-prevention effort combining a women and child rights and empowerment agenda and, critically, lifestyle lessons in a process of cultural renegotiation.

Gender differences in oral manifestations among HIV-infected Brazilian adults

AIM

The purpose of this study was to compare gender differences in the prevalence of oral lesions in HIV-infected Brazilian adults.

METHODOLOGY

A retrospective study was conducted of medical records from HIV/AIDS patients from 1993 to 2004. Oral lesions were only included in this study if definitively diagnosed through microscopic analysis, therapeutic test or according to EC-Clearing house criteria.

RESULTS

A total of 750 men and 237 women were included in the study. Statistically significant differences were observed only for oral hairy leukoplakia, Kaposi sarcoma and lymphadenopathy (P < 0.01). However, a model of logistic regression showed that only oral hairy leukoplakia presented a significant association with gender and males had a significantly likelihood (four times higher than females) of presenting with this oral manifestation [OR 4.3 (95% CI: 1.39-13.36)].

CONCLUSION

These data shows that oral manifestations are less prevalent in females than in males, particularly oral hairy leukoplakia.

A response to Edzi (AIDS): Malawi faith-based organizations' impact on HIV prevention and care

African faith-based organization (FBO) leaders influence their members' HIV knowledge, beliefs, and practices, but their roles in HIV prevention and care are poorly understood. This article expands the work of Garner (2000) to test the impact of FBO influence on member risk and care behaviors, embedding it in the Theory of Planned Behavior. Qualitative interviews and quantitative surveys were collected from five FBOs (Christian and Muslim) in Malawi and analyzed using mixed methods. Contrary to Garner, we found that the level of power and influence of the FBO had no significant impact on the risk-taking behaviors of members; however, leaders' HIV knowledge predicted members' behaviors. Stigmatizing attitudes of leaders significantly decreased members' care behaviors, but FBO hierarchy tended to increase members' care behaviors. The power of local church and mosque leaders to influence behavior could be exploited more effectively by nurses by providing support, knowledge, and encouragement to churches and mosques.

Male migrants' non-spousal sexual partnerships in the place of origin: an in-depth investigation in two rural settings of India

Male migrants in India are at disproportionately high risk for HIV, not only because of their sexual behaviours in destination areas but also due to their risk behaviours in their place of origin. While studies have documented male migrants' risky behaviours in the home setting, few have attempted to understand the underlying socio-cultural context in which they engage in such behaviours. This paper examines the patterns and context of male migrants' non-spousal sexual partnerships in two high-out-migration districts of India. Data, drawn from a cross-sectional behavioural mixed-methods study conducted in 2008, included a structured survey with 1272 migrants, followed by in-depth interviews with 33 male migrants. Results suggest that sexual activity was common in the place of origin: around 50% of migrants had sex with a non-spousal female partner and two-fifths had initiated sex in this setting. Migrants' non-spousal sexual behaviours in the home village were influenced by the prevailing socio-cultural context, including migrants' enhanced socio-economic status, attitudes to non-spousal sex and accessibility of sexual partners. Male migrants' non-spousal sexual partnerships in source areas are influenced by socio-cultural factors, which must be considered when designing HIV programmes in India and elsewhere.

Can interfaith research partnerships develop new paradigms for condom use and HIV prevention? The implementation of conceptual events in Malawi results in a 'spiritualised condom'

Objectives

The aim of this intervention research study was to engage senior leaders of faith-based organisations (FBOs) in Malawi in a participatory process to construct an interfaith theology of HIV/AIDS. This process was designed to enhance the capacity of faith leaders to respond more effectively to the HIV/AIDS pandemic.

Methods

An evidence-driven combination of ethnographic and participatory action research methodologies was utilised. Conceptual events—innovative participatory action research processes—were held over the 4-year project and brought together health service providers, policy makers and a non-governmental organisation in partnership with FBOs and grassroots faith-based communities.

Results

Through facilitated dialogue, an interfaith theology of HIV/AIDS emerged, resulting in the proposition that a ‘spiritualised condom’ endorses a ‘theology of protecting life’. This proposition was based on the following convictions: (1) life is sacred and to be protected, (2) to kill or murder is a ‘greater sin’ than the ‘lesser sin of infidelity’, (3) protection of the innocent is a moral and religious requirement, (4) condoms have the potential to prevent the death of an innocent person and (5) condoms need to be encouraged, even in the context of marriage.

Conclusions

Clinicians, non-governmental organisations, health service providers and policy makers, assisted by health social scientists, can successfully partner with FBOs and their leaders to (1) modify and transform faith-based understandings of HIV risk and (2) bring about attitudinal and behaviour changes that help to address the challenges associated with HIV/AIDS.

Outcomes of an HIV prevention peer group intervention for rural adults in Malawi

This study used a quasi-experimental design to evaluate a six-session peer group intervention for HIV prevention among rural adults in Malawi. Two rural districts were randomly assigned to intervention and control conditions. Independent random samples of community adults compared the districts at baseline and at 6 and 18 months postintervention. Using multiple regressions controlling for six demographic factors, intervention district adults had significantly more favorable outcomes at 6- and 18-month evaluations for condom attitudes, self-efficacy for community prevention, self-efficacy for practicing safer sex, partner communication, using condoms ever in the past 2 months, and community prevention activities. Knowledge and hope for controlling the epidemic were significantly higher in the intervention district only at the 6-month evaluation; having a recent HIV test was significantly higher only at 18 months. Levels of stigma and the number of risky sex practices did not decrease when demographic factors were controlled. Expanding peer group intervention for HIV prevention would benefit rural adults.

Peer group intervention reduces personal HIV risk for Malawian health workers

PURPOSE

To test a peer group intervention to address personal HIV prevention needs of rural health workers in Malawi.

DESIGN

Using a quasi-experimental design, we compared district health workers in two districts of Malawi that were randomly assigned to either the intervention or delayed control condition. We used independent sample surveys at baseline, 15 months, and 30 months postintervention. Intervention district workers received a peer group intervention after the baseline; control district workers received the delayed intervention after final data collection.

METHODS

The 10-session intervention for primary prevention of HIV infection was based on the primary healthcare model, behavioral change theory, and contextual tailoring based on formative evaluation. Differences in HIV-related knowledge, attitudes, self-efficacy, and behaviors were analyzed using t tests and multiple regression controlling for baseline differences.

FINDINGS

Health workers in the intervention district had higher general HIV knowledge, more positive attitudes about condoms, higher self-efficacy for safer sex, and more involvement in community HIV prevention at both the 15-month and 30-month postintervention survey. At 30 months, intervention district workers also reported less stigmatizing attitudes toward persons living with AIDS, more HIV tests, and lower risky sexual behaviors.

CONCLUSION

The intervention should be sustained in current sites and scaled up for health workers throughout Malawi as part of a multisectoral response to HIV prevention.

CLINICAL RELEVANCE

Incorporating a peer group intervention focused on personal as well as work-related HIV prevention can reduce health workers' risky behaviors in their personal lives, potentially reducing morbidity and mortality and enhancing workforce retention. Reducing stigmatizing attitudes may also improve the quality of health services.

Process evaluation of HIV prevention peer groups in Malawi: a look inside the black box

This paper reports the process evaluation of a peer group intervention for human immunodeficiency virus (HIV) prevention which had positive outcomes for three target groups in Malawi: rural adults, adolescents and urban hospital workers. The six-session intervention was delivered to small groups of 10-12 participants by 85 trained volunteer peer leaders working in pairs. A descriptive, observational mixed methods design was used with a convenience sample of 294 intervention sessions. Using project records and a conceptually based observation guide, we examined five aspects of the implementation process. The context was favorable, but privacy to discuss sensitive issues was a concern for some groups. In study communities, program reach was 58% of rural adults, 70% of adolescents and nearly all hospital workers. Session records confirmed that all peer groups received the intended six sessions (dose delivered). The dose received was high, as evidenced by high participant engagement in peer group activities. Peer leaders were rated above the median for three indicators of peer group content and process fidelity: session management skills, interpersonal facilitation skills and whether more like a peer group than classroom. Documenting that this HIV prevention peer group intervention was delivered as intended by trained peer volunteers supports widespread dissemination of the intervention.

Question box: a tool for gathering information about HIV and AIDS

Previous studies on knowledge of HIV transmission and prevention have used surveys. This study used the question box method to create a safe environment for collecting information on knowledge of HIV transmission and prevention. The aim was to encourage young people to ask questions about HIV, which they would otherwise not ask because of fear of being judged negatively, ridiculed, punished or stigmatized. Seven question boxes were placed at each community secondary school in Lilongwe Rural West District of Malawi. In total participants asked 394 questions. Six categories of questions emerged and included: general questions about HIV, sexual practices, perinatal transmission, other modes of transmission, contact/sharing items and prevention and condom use. The question box method created a safe environment for asking sensitive questions anonymously about HIV and AIDS.