Discordance, Disclosure and Normative Gender Roles: Barriers to Couple Testing Within a Community-Level HIV Self-Testing Intervention in Urban Blantyre, Malawi

Kumwenda, Moses; Corbett, Elizabeth L.; Chikovore, Jeremiah; Phiri, Mackwellings; Mwale, Daniel; Choko, Augustine; Nliwasa, Marriott; Sambakunsi, Rodrick; Taegtmeyer, Miriam; Gutteberg, Tore Jarl; Munthali, Alister; Desmond, Nicola

doi:10.1007/s10461-018-2038-0

Cited by 24 publications

(21 citation statements)

References 41 publications

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“…Importantly, illiterate clients were also less likely to be willing to distribute HIVST, reflecting a potential gap in the types of populations that can be reached with secondary HIVST strategies. Similar to other research, a minority of HIV-positive clients noted that lack of trust in the relationship [11,37,38] and harmful gender norms [37,38] may discourage HIVST distribution and use. While index partner HIVST may improve access and use of HIV testing, particularly among male partners, it may still face barriers related to couple dynamics, as seen in other couples-based HIV services.…”

Section: Discussionsupporting

confidence: 73%

Acceptability of index partner HIV self-testing among HIV-positive clients in Malawi: A mixed methods analysis

Offorjebe

Hoffman

Shaba³

et al. 2020

PLoS ONE

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We sought to evaluate whether HIV-positive adults in Malawi were willing to distribute HIV self-testing (HIVST) kits to their sexual partners of unknown HIV status (index HIVST). Design A mixed-methods study was nested within a larger HIVST trial conducted at 15 health facilities in Malawi. Exit surveys were conducted with HIV-positive adults during routine outpatient department visits to assess perceived acceptability of index partner HIVST versus standard partner referral slips that request partner(s) to attend the health facility. Individuals were included in the sub-analysis irrespective of date of HIV diagnosis or ART initiation (or non-initiation). In-depth interviews were conducted with a sub-sample of respondents. Results 404 HIV-positive adults completed a survey (159 male and 245 female); 21 completed indepth interviews. Respondents reported feeling more comfortable distributing HIVST versus partner referral slips to their partners (90% vs. 81%) and expressed confidence that their partners would test using HIVST compared to referral slips (77% vs. 66%). Acceptability of HIVST did not vary by sex. Qualitative data revealed that index HIVST was perceived to be private, convenient, and may strengthen relationships by assisting in serostatus disclosure. There were minimal fears of adverse events. Reported barriers to index HIVST included lack of trust within the relationship and harmful gender norms. Conclusions HIV-positive clients were willing to distribute HIVST kits to their sexual partners of unknown serostatus. Additional studies are needed to evaluate use of HIVST by index partners,

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Section: Discussionsupporting

confidence: 73%

Acceptability of index partner HIV self-testing among HIV-positive clients in Malawi: A mixed methods analysis

Offorjebe

Hoffman

Shaba³

et al. 2020

PLoS ONE

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“…This presents an important opportunity for HIV prevention [48], but also responsibility to ensure that serodiscordancy is understood, with appropriate follow-up advice and management. We identified significant gaps in awareness and understanding of discordancy, both among couples and for health workers, as also reported from other African countries [49][50][51]. Providing clear messages and the need for "Some people when they know that someone has HIV and have started taking ARVs [Antiretroviral] drugs, they feel that they cannot have sex with that person fearing that they can also get infected.…”

Section: Discussionmentioning

confidence: 87%

Exploring social harms during distribution of HIV self‐testing kits using mixed‐methods approaches in Malawi

et al. 2019

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Introduction HIV self‐testing (HIVST) provides couples and individuals with a discreet, convenient and empowering testing option. As with all HIV testing, potential harms must be anticipated and mitigated to optimize individual and public health benefits. Here, we describe social harms (SHs) reported during HIVST implementation in Malawi, and propose a framework for grading and responding to harms, according to their severity. Methods We report findings from six HIVST implementation studies in Malawi (2011 to 2017) that included substudies investigating SH reports. Qualitative methods included focus group discussions, in‐depth interviews and critical incident interviews. Earlier studies used intensive quantitative methods (post‐test questionnaires for intimate partner violence, household surveys, investigation of all deaths in HIVST communities). Later studies used post‐marketing reporting with/without community engagement. Pharmacovigilance methodology (whereby potentially life‐threatening/changing events are defined as “serious”) was used to grade SH severity, assuming more complete passive reporting for serious events. Results During distribution of 175,683 HIVST kits, predominantly under passive SH reporting, 25 serious SHs were reported from 19 (0.011%) self‐testers, including 15 partners in eight couples with newly identified HIV discordancy, and one perinatally infected adolescent. There were no deaths or suicides. Marriage break‐up was the most commonly reported serious SH (sixteen individuals; eight couples), particularly among serodiscordant couples. Among new concordant HIV‐positive couples, blame and frustration was common but rarely (one episode) led to serious SHs. Among concordant HIV‐negative couples, increased trust and stronger relationships were reported. Coercion to test or disclose was generally considered “well‐intentioned” within established couples. Women felt empowered and were assertive when offering HIVST test kits to their partners. Some women who persuaded their partner to test, however, did report SHs, including verbal or physical abuse and economic hardship. Conclusions After more than six years of large‐scale HIVST implementation and in‐depth investigation of SHs in Malawi, we identified approximately one serious reported SH per 10,000 HIVST kits distributed, predominantly break‐up of married serodiscordant couples. Both “active” and “passive” reporting systems identified serious SH events, although with more complete capture by “active” systems. As HIVST is scaled‐up, efforts to support and further optimize community‐led SH monitoring should be prioritized alongside HIVST distribution.

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“…The study presented here took place between March 2015 and December 2015, in urban Blantyre, Malawi. It emerged out of a community-based intervention trial that ran from 2012 to 2015 investigating whether community-level active TB case finding and intensified TB prevention through regular semi-supervised, HIV self-testing (HST) and access to treatment could reduce TB incidence (Choko et al., 2015 ; Kumwenda et al., 2014 ; Kumwenda et al., 2018 ; Sambakunsi et al., 2015 ). This trial was implemented in 28 clusters (14 intervention and 14 control) of high density and low-resource urban settlements with relatively high rates of social migration and many residents reliant on a range of informal and unreliable income-generating activities.…”

Section: Methodsmentioning

confidence: 99%

“Not just dogs, but rabid dogs”: tensions and conflicts amongst research volunteers in Malawi

et al. 2018

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Building trust between researchers and communities involved in research is one goal of community engagement. This paper examines the implications of community engagement for trust within communities, including trust among community volunteers who assist with research and between these volunteers and other community members. We describe the experiences of two groups of community volunteers recruited as part of an HIV and TB intervention trial in Malawi: cluster representatives, recruited both to act as key informants for TB suspects and mortality reporting and to identify and report community concerns, and community counsellors, recruited to provide semi-supervised HIV self-testing. We examine tensions experienced due to playing multiple roles, and the implications of volunteer responsibilities for short- and long-term community relationships. Data was collected through a workshop, in-depth interviews and focus group discussions with volunteers and community members. While the volunteer system initially enhanced trust among volunteers and with the community, relationships deteriorated when cluster representatives assumed an additional supervisory role part-way through the trial. Combined with challenging recruitment targets and unequal power relations between volunteers, this new role damaged trust, with implications for volunteer well-being and social relationships. These experiences suggest researchers should consider potential social implications when designing community engagement systems.

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Discordance, Disclosure and Normative Gender Roles: Barriers to Couple Testing Within a Community-Level HIV Self-Testing Intervention in Urban Blantyre, Malawi

Cited by 24 publications

References 41 publications

Acceptability of index partner HIV self-testing among HIV-positive clients in Malawi: A mixed methods analysis

Acceptability of index partner HIV self-testing among HIV-positive clients in Malawi: A mixed methods analysis

Exploring social harms during distribution of HIV self‐testing kits using mixed‐methods approaches in Malawi

“Not just dogs, but rabid dogs”: tensions and conflicts amongst research volunteers in Malawi

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