Combining Qualitative and Quantitative Evidence to Determine Factors Leading to Late Presentation for Antiretroviral Therapy in Malawi

Abstract

BackgroundTreatment seeking delays among people living with HIV have adverse consequences for outcome. Gender differences in treatment outcomes have been observed in sub-Saharan Africa.ObjectiveTo better understand antiretroviral treatment (ART) seeking behaviour in HIV-infected adults in rural Malawi.MethodsQualitative interviews with male and female participants in an ART cohort study at a treatment site in rural northern Malawi triangulated with analysis of baseline clinical and demographic data for 365 individuals attending sequentially for ART screening between January 2008 and September 2009.Results43% of the cohort presented with late stage HIV disease classified as WHO stage 3/4. Respondents reported that women's frequency of testing, health awareness and commitment to children led to earlier ART uptake and that men's commitment to wider social networks of influence, masculine ideals of strength, and success with sexual and marital partners led them to refuse treatment until they were sick. Quantitative analysis of the screening cohort provided supporting evidence for these expressed views. Overall, male gender (adjusted OR 2.3, 95% CI1.3–3.9) and never being married (adjusted OR 4.1, 95% CI1.5–11.5) were risk factors for late presentation, whereas having ≥3 dependent children was associated with earlier presentation (adjusted OR 0.31, 95% CI0.15–0.63),compared to those with no dependent children.ConclusionGender-specific barriers and facilitators operate throughout the whole process of seeking care. Further efforts to enrol men into care earlier should focus on the masculine characteristics that they value, and the risks to these of severe health decline. Our results emphasise the value of exploring as well as identifying behavioural correlates of late presentation.

What role can gender-transformative programming for men play in increasing men’s HIV testing and engagement in HIV care and treatment in South Africa?

“…In large multi-site cohort studies of persons living with HIV in South Africa who had initiated ARV treatment, men were significantly more likely than women to be lost to follow-up (Cornell et al 2014), have a lower median CD4+ count, and higher crude and age-adjusted mortality (Cornell et al 2012). Researchers in other settings in sub-Saharan Africa have found similar differences between men and women (Bila and Egrot 2009; Gari et al 2014; Parrott et al 2011). To reduce HIV transmission through HIV testing/care/treatment, it is therefore essential to improve our understanding of the barriers that are unique to men and what programmes can do to ameliorate this gender difference.…”

Antiretroviral Treatment Outcomes amongst Older Adults in a Large Multicentre Cohort in South Africa

“…In addition, it may be related to gender differences in health-seeking behaviour as men tend to delay their presentation for treatment until later stages of infection [51], [52].…”

Late Presentation to Care among People Living with HIV in Cotonou, Benin: A Retrospective Analysis from 2003 to 2014

“…In Benin as well as in other African countries, the issue of late presentation to care is not a restricted HIV concern. It is common with many diseases and is caused by the social and cultural behaviors toward diseases, financial constraints and faith in spiritual treatments [16] [17]. Patients usually seek care from healers first and they only go to hospitals when advanced stages of their diseases are reached [17].…”

“…It is common with many diseases and is caused by the social and cultural behaviors toward diseases, financial constraints and faith in spiritual treatments [16] [17]. Patients usually seek care from healers first and they only go to hospitals when advanced stages of their diseases are reached [17]. As far as HIV is concerned, stigma, being unaware of HIV-status could also explain these results [18].…”