In sub-Saharan Africa, most new HIV infections occur in stable relationships, making couples testing an important intervention for HIV prevention. We explored factors shaping the decision-making of cohabiting couples who opted to self-test in Blantyre, Malawi. Thirty-four self-tested participants (17 couples) were interviewed. Motivators for HIV self-testing (HIVST) emerged at three main levels. Individual motivations included perceived benefits of access to treatment, and self-checking of serostatus in the hope of having been cured by prolonged treatment or faith-healing. HIVST was considered convenient, confidential, reassuring and an enabling new way to test with one’s partner. Partnership motivations included both positive (mutual encouragement) and negative (suspected infidelity) aspects. For women, long-term health and togetherness were important goals that reinforced motivations for couples testing, whereas men often needed persuasion despite finding HIVST more flexible and less onerous than facility-based testing. Internal conflict prompted some partners to use HIVST as a way of disclosing their previously concealed HIV positive serostatus. Thus, the implementation of community-based HIVST should acknowledge and appropriately respond to decision-making processes within couples, which are shaped by gender roles and relationship dynamics.

IntroductionLinkage from HIV testing and counselling (HTC) to initiation of antiretroviral therapy (ART) is suboptimal in many national programmes in sub-Saharan Africa, leading to delayed initiation of ART and increased risk of death. Reasons for failure of linkage are poorly understood.MethodsSemi-structured qualitative interviews were undertaken with health providers and HIV-positive primary care patients as part of a prospective cohort study at primary health centres in Blantyre, Malawi. Patients successful and unsuccessful in linking to ART were included.ResultsProgression through the HIV care pathway was strongly influenced by socio-cultural norms, particularly around the perceived need to regain respect lost during a period of visibly declining health. Capacity to call upon the support of networks of families, friends and employers was a key determinant of successful progression. Over-busy clinics, non-functioning laboratories and unsuitable tools used for ART eligibility assessment (WHO clinical staging system and centralized CD4 count measurement) were important health systems determinants of drop-out.ConclusionsKey interventions that could rapidly improve linkage include guarantee of same-day, same-clinic ART eligibility assessments; utilization of the support offered by peer-groups and community health workers; and integration of HTC and ART programmes.

ObjectiveTo understand reasons for suboptimal and delayed uptake of antiretroviral therapy (ART) by describing the patterns of HIV testing and counselling (HTC) and outcomes of ART eligibility assessments in primary clinic attendees.MethodsAll clinic attendances and episodes of HTC were recorded at two clinics in Blantyre. A cohort of newly diagnosed HIV-positive adults (>15 years) was recruited and exit interviews undertaken. Logistic regression models were constructed to investigate factors associated with referral to start ART. Qualitative interviews were conducted with providers and patients.ResultsThere were 2398 episodes of HTC during 18 021 clinic attendances (13.3%) between January and April 2011. The proportion of clinic attendees undergoing HTC was lowest in non-pregnant women (6.3%) and men (8.5%), compared with pregnant women (47.2%). Men had more advanced HIV infection than women (79.7% WHO stage 3 or 4 vs. 56.4%). Problems with WHO staging and access to CD4 counts affected ART eligibility assessments; only 48% completed ART eligibility assessment, and 54% of those reporting WHO stage 3/4 illnesses were not referred to start ART promptly. On multivariate analysis, HIV-positive pregnant women were significantly less likely to be referred directly for ART initiation (adjusted OR: 0.29, 95% CI: 0.13–0.63).ConclusionsThese data show that provider-initiated testing and counselling (PITC) has not yet been fully implemented at primary care clinics. Suboptimal ART eligibility assessments and referral (reflecting the difficulties of WHO staging in primary care) mean that simplified eligibility assessment tools are required to reduce unnecessary delay and attrition in the pre-ART period. Simplified initiation criteria for pregnant women, as being introduced in Malawi, should improve linkage to ART.

BackgroundFor years, Malawi remained at the bottom of league tables on maternal, neonatal and child health. Although maternal mortality ratios have reduced and significant progress has been made in reducing neonatal morality, many challenges in achieving universal access to maternal, newborn and child health care still exist in Malawi. In Malawi, there is still minimal, though increasing, male involvement in ANC/PMTCT/MNCH services, but little understanding of why this is the case. The aim of this paper is to explore the role and involvement of men in MNCH services, as part of the broader understanding of those community system factors.MethodsThis paper draws on the qualitative data collected in two districts in Malawi to explore the role and involvement of men across the MNCH continuum of care, with a focus on understanding the community systems barriers and enablers to male involvement. A total of 85 IDIs and 20 FGDs were conducted from August 2014 to January 2015. Semi-structure interview guides were used to guide the discussion and a thematic analysis approach was used for data analysis.ResultsPolicy changes and community and health care provider initiatives stimulated men to get involved in the health of their female partners and children. The informal bylaws, the health care provider strategies and NGO initiatives created an enabling environment to support ANC and delivery service utilisation in Malawi. However, traditional gender roles in the home and the male ‘unfriendly’ health facility environments still present challenges to male involvement.ConclusionTraditional notions of men as decision makers and socio-cultural views on maternal health present challenges to male involvement in MNCH programs. Health care provider initiatives need to be sensitive and mindful of gender roles and relations by, for example, creating gender inclusive programs and spaces that aim at reducing perceptions of barriers to male involvement in MNCH services so that programs and spaces that are aimed at involving men are designed to welcome men as full partners in the overall goals for improving maternal, neonatal and child health outcomes.Electronic supplementary materialThe online version of this article (10.1186/s12884-017-1523-1) contains supplementary material, which is available to authorized users.

Traditional leaders play a prominent role at the community level in Malawi, yet limited research has been undertaken on their role in relation to policy implementation. This article seeks to analyse the role of traditional leaders in implementing national maternal, newborn and child health (MNCH) policy and programmes at the community level. We consider whether the role of the chief embodies a top-down (utilitarian) or bottom-up (empowerment) approach to MNCH policy implementation. Primary data were collected in 2014/15, through 85 in-depth interviews and 20 focus group discussions in two districts in Malawi. We discovered that traditional leaders play a pivotal role in supporting MNCH service utilization, through mobilization for MNCH campaigns, and encouraging women to give birth at the health facility rather than at home or in the community setting. Women and their families responded to bylaws to deliver in the facility out of respect for the traditional leader, which is ingrained in Malawian culture. Fines were imposed on women for delivering at home, in the form of goats, chickens and money. Fear and coercion were often used by traditional leaders to ensure that women delivered at the health facility. Chiefs who failed to enforce these bylaws were also fined. Although the role of the traditional leader was often positive and encouraging in relation to MNCH service utilization, this was sometimes carried out in a coercive manner. Results show evidence of a utilitarian top-down model of policy implementation, where the goal of health service utilization justified the means, through encouragement, fear, punishment or coercion. Although the bottom-up approach would be associated with a more empowerment approach, it is unlikely that this would have been successful in Malawi, given the hierarchical nature of society. Further research on policy implementation in the context of community participation is needed.