The findings highlighted that many men discourage their partners from initiating or adhering to ART. Universal ART offers a unique opportunity to curb the epidemic, but successful implementation of these new guidelines is dependent on ART initiation and adherence by both women and men. Many people face challenges starting and remaining on antiretroviral treatment ART , the medication recommended for those with human immunodeficiency virus HIV. Data were collected using individual in-depth interviews and focus group discussions of 6—12 people.
Data were collected with HIV-positive pregnant and postpartum women and health care workers in two countries in sub-Saharan Africa, Malawi and Zimbabwe. The findings highlighted that across the study settings women commonly experience their male partners discouraging them from initiating and adhering to ART. In , an estimated With the new guidelines, there is expected to be a significant increase in the number of people who will now be eligible for ART.
Modelling studies have suggested that expansion of ART coverage could be effective in reducing transmission at the population level [ 6 ]. Previous research has demonstrated challenges with initiating seemingly healthy asymptomatic individuals on lifelong ART irrespective of their CD4 cell count. A study in Canada found that The change in guidelines to universal ART conflicted with the information they had previously received regarding when to start ART. These participants were proud of their ability to maintain a high CD4 count and regarded delaying ART initiation as a major accomplishment [ 8 ].
At the time of writing, some countries have begun implementing universal ART as national policy; however, little is known about the effects of universal ART on the social dynamics of disclosure processes, adherence and retention [ 9 ]. Previous studies have demonstrated the challenges of getting men to access health facilities, test for HIV and initiate and adhere to ART [ 10 , 11 , 12 ]. Men are generally initiating ART much later and have worse outcomes than women [ 15 ].
One study from South Africa found that men had 4. Previous studies have reported that men only access HIV services when in late stage disease [ 17 , 18 , 19 ]. With the history of male reluctance to undergo HIV testing and receive treatment, there is an urgent need to tailor programs to the needs of men. This descriptive qualitative study in Malawi and Zimbabwe collected data using in-depth interviews IDIs and focus group discussions FGDs to explore the acceptability of initiating lifelong ART with pregnant and breastfeeding women.
Results from Malawi have been published [ 20 ]. While the study was conducted in different contexts, findings were very similar and therefore have been combined in this paper to strengthen the transferability of the results. Comparing the results of the two country contexts drew attention to the challenges men are facing to engage in HIV testing and treatment. The findings would be most applicable in a low-income setting, with a patriarchal society and over-stressed health care systems. In Malawi, four health care facilities were selected as the study sites.
The districts of Lilongwe, Dedza and Mchinji were purposively selected for their rural, urban and peri-urban settings. In addition, different facility types including government-owned free services or privately-owned pay-for services were selected. Within these parameters, the sites with the highest volume of HIV-positive pregnant women were selected.
In Zimbabwe, the urban and rural districts of Harare and Zvimba were selected based on their relatively close proximity to the city of Harare. Once the districts were chosen, eight public health facilities free services with the highest annual volume of HIV-positive pregnant women were selected. No decision can be made without consulting the man, so she is in a submissive kind of situation. Malawi and Zimbabwe have similar population sizes, Malawi has a population of approximately 18,, and Zimbabwe a population of approximately 16,, [ 25 ].
Malawi has nine main ethnic groups while Zimbabwe is more homogenous with two primary ethnic groups. Both Malawi and Zimbabwe are predominantly Christian. Malawi has a higher fertility rate of 4. Zimbabwe has an adult HIV prevalence of In Malawi saw an estimated new infections among children, while Zimbabwe had an estimated HCWs identified eligible women and referred them to onsite RAs.
All study participants voluntarily agreed and signed written informed consent forms. Confidentiality was discussed during the informed consent process and at the beginning of the FGDs. The data collection tools used in Malawi were adapted to fit the Zimbabwe context. Both versions of the data collection tools for the pregnant and postpartum women focused on the following: understanding general perceptions towards lifelong ART; messages provided at the clinic by HCWs; perspectives in the community; barriers and facilitators to initiating and adhering to ART; male involvement; disclosure, and support received.
Single interviewers conducted the IDIs; a moderator with a note-taker conducted the FGDs which consisted of 6—12 participants. All IDIs and FGDs were audio-recorded to ensure that the data were accurately captured without subjective filtering of information. Data from the studies conducted in Malawi and Zimbabwe were analyzed separately using thematic analysis. All transcripts were entered into MAXqda v. Transcripts were reviewed by the study team, and a code list representative of the findings was created.
The code lists were circulated among each study team, including the in-country staff to ensure that it accurately reflected the data. The code list was updated several times based on feedback. Related codes were grouped into overarching themes. Data were analyzed by study population. Data reduction and summary tables were created to organize the results and track the emergence of themes from the data.
Quotes were selected from both countries to illustrate thematic findings. In Malawi, a total of 19 IDIs were conducted with pregnant women and 20 with postpartum women. In both countries, the majority of participants were married. The mean age for women in Malawi was Women felt that the lack of knowledge was a significant challenge and mentioned the need for the men to be educated on HIV and ART. It was commonly reported in both Zimbabwe and Malawi that men refused to get tested for HIV even when feeling ill.
Men avoided getting tested for HIV even when visiting the health facility. I told him and he sneaked away from the ward, running away from seeing the nurse. He drove his car and went away. So, from that day he does not want to hear about it. This is what he says and there is no way to argue with him. While many women reported that their male partner refused to engage in HIV testing, women in both countries reported believing that their male partners knew their HIV status but chose to keep it a secret until the woman learned her HIV status.
Study participants reported that their partners knew they were HIV-positive but failed to disclose their results. I suppose that is where he got HIV infected. I only discovered much later that he was positive because of my visit to the clinic. These men can be so heartless and deceiving. Some women believed that their male partners had tested positive for HIV and had been secretly taking antiretroviral drugs ARVs. So men are the most cunning ones. I suppose he knew I would find out eventually on my own at the hospital.
The time I was beginning the process of getting my ARVs, he had already been taking them for a whole year. While there were several cases of women reporting that their partner was secretly taking ART, it was more commonly reported that men refuse to initiate ART after learning that they are HIV-positive. A Zimbabwean participant suggested creating a special space for men where they would be comfortable receiving services.
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This would also be a place where the men can be given instruction or education on HIV. Men need to be instructed on why and how to take the medication and to remind their partners. Culturally, for women to talk to men it is misconstrued to be women challenging men. If a man speaks to fellow men they can listen. References were made in both Malawi and Zimbabwe about the man being the head of the house and having the final say in all decisions regarding his partner and family.
Women often demonstrate a commitment to initiate and adhere to ART, but men may discourage or prevent their partners from initiating and adhering to ART. Religion has been documented as both a barrier and facilitator to ART adherence. Some religious leaders claim that prayer can cure HIV and that drugs should not be taken. Some women reported receiving incorrect advice from their partners encouraging them to stop their medication.
Partners were also viewed as a facilitator to ART initiation and adherence. While, women frequently discussed their partner as a barrier to ART initiation and adherence, some women reported that their partner was supportive of them being on ART, provided emotional support and helped to remind them to take their medication. He was not disturbed much at that time because the counsellors sat down with us and taught us. When we got home, it was me who got stressed and I even lost weight. He was even encouraging me to take my medicine and warning me against defaulting, saying if I default, I will die.
He would wake up, cook for me and giving me my medicine to take. Even after I gave birth, he knows what time to give medicine to our baby. Before he goes to work, he makes sure he gives our baby medicine. Study participants described beliefs they had heard in the community such as HIV is a death sentence, ART is only for very sick people, and ART is a complicated multi-drug regimen.
The lack of knowledge about the developments in HIV care and treatment highlight a clear gap in how communities are being informed and educated about changing public health practices. Many women discussed old sentiments about HIV being a death sentence in the community. These kinds of beliefs were prevalent in both countries and deterred both women and men from initiating and adhering to treatment. Zimbabwe, lactating woman.
Ideas of ART being for the very ill have also continued to linger through images used at the health facility. Some women commented on the visual depictions at the facility indicating that ART is for the very ill. One of the most challenging aspects of earlier HIV care was the large cocktail of drugs required multiple times a day. My husband used to comment saying if he was to test HIV positive, he would be happy to hear that he can wait a little while before initiating ART because of the burden of taking many tablets at a time.
Now, he accepts it more because people on ART are now taking just one tablet a day. Those who are utilizing the facility, such as pregnant and postpartum women, have the opportunity to learn about advancements in HIV care and treatment. In both Malawi and Zimbabwe concerns of side-effects from the drugs resulting in disfiguration were mentioned. Stavudine was a drug used in earlier ART regimens which caused disfiguration; however, it has not been communicated widely to the public that this drug is no longer in use. Reduction of HIV transmission on a population level requires successful acceptance of ART by the communities to which these new guidelines are targeted.
Two primary theories have emerged to explain why men do not engage in HIV testing and treatment. The first theory suggests that HIV testing and treatment threatens traditional norms of masculinity [ 19 , 32 ]. The second theory hypothesizes that health services have been designed for women, and men have been systematically left out [ 10 ].
These theories are also influenced by contextual barriers including poverty, stigma and distrustful and difficult relationships with HCWs [ 33 ]. The findings of this study build on these two theories and provide an additional perspective; that outdated beliefs about HIV care and treatment deter men from engaging in HIV testing and treatment. Outdated beliefs such as HIV is a death sentence, ART is only for the very ill, ART is a complicated, multi-drug regimen with visible side-effects and the lack of knowledge that one can live a long healthy life on ART discourage men from initiating HIV testing and treatment and supporting their partners.
Hegemonic masculinity has been associated with men having multiple sexual partners, being viewed as powerful, risk takers, providers and tough in the face of illness [ 35 ]. The fear of receiving a HIV test is well documented in the literature, with previous studies highlighting fears of loss of masculinity, power, and pride with an HIV-positive test result [ 11 , 17 ]. Local notions of masculinity disfavor seeking help because it is thought to be a sign of weakness [ 36 , 37 ]. As a result, men often wait to access the health facility until they are very ill [ 37 ]. HIV is associated with being weak, vulnerable, and requiring help [ 17 ].
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