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Background: With the introduction of 2016 World Health Organization guidelines recommending universal antiretroviral therapy (ART), there has been increased recognition of the lack of men engaging in HIV testing and treatment. Studies in sub-Saharan Africa indicate there have been challenges engaging men in HIV testing and HIV-positive men into treatment. Methods: This qualitative study explored women’s perspective of their male partner’s attitudes towards HIV and ART and how it shapes woman’s experience with ART. Data were collected through in-depth interviews and focus group discussions with HIV-positive pregnant and postpartum women on Option B+ and health care workers in Malawi and Zimbabwe. In Malawi, 19 in-depth interviews and 12 focus group discussions were conducted from September-December 2013. In Zimbabwe, 15 in-depth interviews and 21 focus-group discussions were conducted from July 2014-March 2014. Results: The findings highlighted that many men discourage their partners from initiating or adhering to ART. One of the main findings indicated that despite the many advancements in HIV care and ART regimens, there are still many lingering negative beliefs about HIV and ART from the earlier days of the epidemic. In addition to existing theories explaining men’s resistance to/absence in HIV testing and treatment as a threat to their masculinity or because of female-focused health facilities, this paper argues that men’s aversion to HIV may be a result of old beliefs about HIV and ART which have not been addressed. Conclusions: Due to lack of accurate and up to date information about HIV and ART, many men discourage their female partners from initiating and adhering to ART. The effect of lingering and outdated beliefs about HIV and ART needs to be addressed through strengthened communication about developments in HIV care and treatment. 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. Strengthening men’s understanding about HIV and ART will greatly enhance women’s ability to initiate and adhere to ART and improve men’s health.
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. As the first country to pilot Option B+, Malawi was selected for the study. Zimbabwe was selected as a comparative case for its interest in assessing the acceptability of Option B+ at pilot sites. The study was initially conducted in Malawi in 2013 and then modified for Zimbabwe’s context and conducted in Zimbabwe in 2014. Results from Malawi have been published [20]. The primary focus of the studies in Malawi and Zimbabwe was the acceptability of Option B+. During analysis it was discovered that both data sets had in-depth information about women’s perspectives about their male partners’ attitudes towards HIV and ART. This data provided a unique opportunity to explore how women understand and interpret men’s attitudes towards HIV and ART and how it shapes the woman’s experience with ART. Results illustrating the challenges and fears experienced by men as perceived by the pregnant and postpartum partners and the influence of the male partner on women’s ability to initiate and adhere to ART are presented here. 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 both Malawi and Zimbabwe, the study population was comprised of pregnant and postpartum women initiated on Option B+ and health care workers (HCWs) who provided PMTCT services. Pregnant women were at least 18 years of age, HIV-positive, receiving the ART regimen associated with Option B+ and receiving antenatal care (ANC) from one of the selected study sites. Postpartum women met the same selection criteria in addition to having delivered and breastfed a child within the last 18 months. HCWs had to have worked in the selected health care facilities for the previous six months providing maternal and child health services, including PMTCT. 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. Malawi and Zimbabwe share similar characteristics of predominantly patriarchal societies where the male partner is considered the ‘head of the house’ and women’s ability to make decisions for themselves or family is limited [21, 22]. In a study in Malawi and Zimbabwe participants reported the wife is supposed to be seen as ‘silent, subordinate and submissive.’ “Culture says that she has to be submissive because the head of the house is a man, he is the breadwinner, he takes care of the family. No decision can be made without consulting the man, so she is in a submissive kind of situation.” (p.182) [23]. Male dominant attitudes limit a woman’s choices about her sexuality, use of contraception, decisions around having children, the welfare of her and the children and control over household finances and resources [24]. Malawi and Zimbabwe have similar population sizes, Malawi has a population of approximately 18,300,000 and Zimbabwe a population of approximately 16,300,000 [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 4.9 children per woman, compared to 3.7 children per woman in Zimbabwe [26]. Malawi has an adult (15–49 years) HIV prevalence of 10.0% [27]. Zimbabwe has an adult HIV prevalence of 14.7% [28]. In Zimbabwe, the HIV prevalence among pregnant women 15–49 years has declined from 16.1% in 2009 to 15.9% in 2012 [29]. In 2010 in Malawi, the HIV prevalence among HIV-positive pregnant women was reported to be 10.6% [30]. In both countries eight of ten HIV-positive pregnant women access ART [28, 31]. In 2015 Malawi saw an estimated 4800 new infections among children, while Zimbabwe had an estimated 4900. In 2015, approximately 15,000 women acquired HIV in Malawi compared 32,000 women in Zimbabwe. According to the UNAIDS 2016 estimates, the overall MTCT rate is reported to be 9% in Malawi [31] and 7% in Zimbabwe [28]. Data were collected in Malawi during September –December 2013 and in Zimbabwe from July 2014–March 2015 with trained research assistants (RAs). Reflexivity was discussed during the data collection training and RAs were trained to reflect upon their pre-understanding of the study topic areas and how that could influence how they asked questions and selected follow-up questions, potentially introducing bias. Pregnant and postpartum women were selected using convenience sampling, they were recruited as they arrived at the health facility. HCWs identified eligible women and referred them to onsite RAs. Pregnant and post-partum women participated in both IDIs and FGDs, while HCWs only participated in FGDs. Eligible HCWs were identified by the nurse in-charge and referred to the RAs. All eligible HCWs were invited to participate in FGDs in both Malawi and Zimbabwe. 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. The FGD guides for the HCW asked about aforementioned items in addition to asking about the HCW’s preparation and attitudes towards providing Option B+. Single interviewers conducted the IDIs; a moderator with a note-taker conducted the FGDs which consisted of 6–12 participants. IDIs with pregnant and postpartum women took approximately 65 minutes , FGDs with pregnant and postpartum women averaged two hours and FGDs with HCWs averaged two hours and 35 minutes. In Malawi data were collected in the local language of Chichewa, and Zimbabwe data was collected in the local language of Shona (although some FGDs with HCWs were conducted in English). All IDIs and FGDs were audio-recorded to ensure that the data were accurately captured without subjective filtering of information. Audio-recordings were simultaneously transcribed and translated, including descriptions of the participant’s body language and non-verbal response. The study coordinator reviewed approximately 10% of the transcripts while listening to the audio-recording to ensure the translations were accurate. Data from the studies conducted in Malawi and Zimbabwe were analyzed separately using thematic analysis. All transcripts were entered into MAXqda v.10. 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. Results from both countries that focused on women’s perspectives of men’s attitude towards HIV testing and treatment and how men influenced their partner’s ART initiation and adherence were reviewed using the data reduction and summary tables and code reports. Quotes were selected from both countries to illustrate thematic findings. Ethical approval was received in Malawi from the Malawi Ministry of Health National Health Sciences Research Committee. In Zimbabwe, the study received ethical approval from the Medical Research Council of Zimbabwe.
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