Men “missing” from population-based HIV testing: insights from qualitative research

Abstract

Men’s uptake of HIV testing is critical to the success of “test and treat” strategies in generalized epidemics. This study sought to identify cultural factors and community processes that influence men’s HIV testing uptake in the baseline year of an ongoing test-and-treat trial among 334,479 persons in eastern Africa (SEARCH, NCT#01864603). Data were collected using participant observation at mobile community health campaigns (CHCs) (n = 28); focus group discussions (n = 8 groups) with CHC participants; and in-depth interviews with care providers (n = 50), leaders (n = 32), and members (n = 112) of eight communities in Kenya and Uganda. An 8-person research team defined analytical codes and iteratively refined them during data collection using grounded theoretical approaches, and textual data were coded using Atlas.ti software. Structural and cultural barriers, including men’s mobility and gender norms valorizing risk-taking and discouraging health-seeking behavior, were observed, and contributed to men’s lower participation in HIV testing relative to women. Men’s labor opportunities often require extended absences from households: during planting season, men guarded fields from monkeys from dawn until nightfall; lake fishermen traveled long distances and circulated between beaches. Men often tested “by proxy”, believing their wives’ HIV test results to be their status. Debates about HIV risks were vigorous, with many men questioning “traditional” masculine gender norms that enhanced risks. The promise of antiretroviral therapy (ART) to prolong health was a motivating factor for many men to participate in testing. Flexibility in operating hours of HIV testing including late evening and weekend times along with multiple convenient locations that moved were cited as facilitating factors enhancing male participating in HIV testing. Mobile testing reduced but did not eliminate barriers to men’s participation in a large-scale “test & treat” effort. However, transformations in gender norms related to HIV testing and care-seeking are underway in eastern Africa and should be supported.

Population mobility associated with higher risk sexual behaviour in eastern African communities participating in a Universal Testing and Treatment trial

“…Prior research from Tanzania found that men living apart from their wives did not report more extramarital sex than men who co‐resided with their wives, but the opposite was true for women, among whom those living apart reported extramarital sex more often . Normative masculinities in these settings are such that men's extramarital affairs, while often leading to marital strife, are common and even valorised . In Kenya, funerals are multi‐day gatherings of friends and family at the home of the deceased, accompanied by music and dancing; these are also occasions in which casual, transactional unprotected sex is common .…”

High levels of retention in care with streamlined care and universal test and treat in East Africa

“…The streamlined care system employed by the clinics, which decreased the frequency and improved the efficiency of visits, could have particularly benefited men by reducing any disruption to employment or other work. In these communities in rural East Africa a large proportion of the men work as farmers or fishermen, which requires them to be away from their communities for extended periods, and has been a demonstrated to deter men from to facility-based testing[35]. Men did require additional effort through retention tracking to stay in care, and may have benefited from this individualized outreach.…”

Comparative assessment of five trials of universal HIV testing and treatment in sub‐Saharan Africa

“…Besides characterizing the trial populations with standard socio‐demographic information, these trials also collect experiences and perceptions of a sample of trial participants, community members and services providers. Such qualitative research provides evidence to understand the acceptability of the UTT strategies by the general population 29, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69. Overall, the analysis of the various themes addressed within these five trials will contribute to understanding the impact of UTT strategies in various contexts as well as inform the generalization of such a strategy to new contexts.…”