"Dispense antiretrovirals daily!" restructuring the delivery of HIV services to optimize antiretroviral initiation among men in Malawi

Health care workers' perceptions and bias toward men as HIV clients in Malawi and Mozambique: A qualitative study

Men are underrepresented in HIV services throughout sub-Saharan Africa. Little is known about health care worker (HCW) perceptions of men as clients, which may directly affect the quality of care provided, and HCWs' buy-in for male-specific interventions. Focus group discussions (FGDs) were conducted in 2016 with HCWs from 15 facilities across Malawi and Mozambique and were originally conducted to evaluate barriers to universal treatment (not HCW bias). FGDs were conducted in local languages, recorded, translated to English, and transcribed. For this study, we focused on HCW perceptions of men as HIV clients and any explicit bias against men, using inductive and deductive coding in Atlas.ti v.8, and analyzed using constant comparison methods. 20 FGDs with 154 HCWs working in HIV treatment clinics were included. Median age was 30 years, 59% were female, and 43% were providers versus support staff. HCWs held strong explicit bias against men as clients. Most HCWs believed men could easily navigate HIV services due to their elevated position within society, regardless of facility-level barriers faced. Men were described in pejorative terms as ill-informed and difficult clients who were absent from health systems. Men were largely seen as "bad clients" due to assumptions about men's 'selfish' and 'prideful' nature, resulting in little HCW sympathy for men's poor use of care. Our study highlights a strong explicit bias against men as HIV clients, even when gender and bias were not the focus of data collection. As a result, HCWs may have little motivation to implement male-specific interventions or improve provider-patient interactions with men. Framing men as problematic places undue responsibility on individual men while minimizing institutional barriers that uniquely affect them. Bias in local, national, and global discourses about men must be immediately addressed.

"Men Are Scared That Others Will Know and Will Discriminate Against Them So They Would Rather Not Start Treatment." Perceptions of Heterosexual Men on HIV-Related Stigma in HIV Services in Blantyre, Malawi

BACKGROUND

Although the concept of treatment as prevention has generated optimism that an AIDS-free generation is within reach, the success of this approach centers upon early diagnosis and linkages to care for people living with HIV. Unfortunately, people continue to present for HIV care at late stages of disease and HIV-related stigma has been recognized as the major impediment to HIV prevention and treatment efforts. Given the relevance of addressing stigma to improve access and utilization of HIV services among men, this secondary analysis assessed perceptions of heterosexual men in HIV-related stigma on HIV testing and ART services in Blantyre District.

METHODS

Purposive sampling was done with maximum variation which included men with unknown statuses, newly diagnosed with HIV infection and not yet on ARVs and those with HIV infection on ART. These participants were varied according to age and area of residency and included men from urban, semi urban and rural areas. Health care workers were included depending in the participation in the provision of HIV services. Eighteen (18 IDIs) and sixteen (16) KIIs were done at private facilities and a total of twenty (20) IDS and seventeen (17) KIIs interviews were conducted at public facilities and fourteen (14) FGD were conducted at public facilities as well. The data were collected from January to July 2017 and March to September 2018.

RESULTS

Men perceived that there are barriers and enablers that influence men from accessing HIV testing and ART services. These factors include individuals, family, community and workplace. The surroundings can be a person, community and a family and it plays an integral part in ones' decision to get tested or initiate on ART. At all these levels, men would navigate the options of accessing the services while risking stigma and discrimination.

CONCLUSION

HIV-related stigma exists and impedes access to HIV testing and ART services in men. Men preferred private hospitals to public facilities because of their ability to maintain respect to privacy and confidentiality to their client's. Imitating these policies into the public hospitals can help to improve the perception of HIV-related stigma in heterosexual men.