Male involvement crucial for keeping women on Option B+ in Malawi
A lack of male involvement in their partner’s HIV treatment programme before and after pregnancy has been found to be one of the biggest challenges to retaining women in HIV care in Malawi.
Malawi was one of the first countries to implement Option B+, a prevention of mother-to-child transmission (PMTCT) programme based on test-and-treat – where women start treatment for life when they become pregnant. However, key challenges need to be overcome to retain these women in care over the long term.
In July 2011, the Malawian Ministry of Health initiated Option B+, resulting in a seven-fold increase in the number of women accessing treatment for PMTCT in the first year alone. But keeping women in care and loss to follow-up (LTFU) are major issues. In 2001, for example, 17% of women were LTFU after six months.
To understand better why so many women accepted antiretroviral drugs, but never returned to the clinic for further care, a study was conducted to explore the challenges in Malawi relating to care retention for women on Option B+, from both the women’s perspective and that of the healthcare worker.
The inclusion of men in HIV care was the most commonly cited challenge, as men often perceive pregnancy as a woman’s issue. Even where the man was supportive of a women taking her treatment and staying in care, there was a continuous reluctance on their part to go and get tested for HIV if they did not know their status.
Healthcare workers also noted that they did not know how to follow-up with mothers who they knew were defaulting. If men were involved in antenatal care, they could understand and support the women to go to the clinic, even when they were healthy and on treatment. This would help address the problem that many women decide not to return when they feel better.
Both healthcare workers and women agreed that getting more men in for couples counselling and testing was a critical means to improving Option B+ programming.
Distance to the clinic and concerns about privacy were also big obstacles for staying in care – with many women worrying that other people in the community would see them collecting their ART.
One woman commented, “If you meet a person who knows you and is seeing you enter the room where we get ARVs [antiretrovirals], they tend to tell people that so and so are on ARVs.”
The main worry for them in this instance is stigma and discrimination from the wider community. Many women only disclosed their status to either one person or a small group of people. Some even reported that family members would no longer visit the house, and one women reported that her husband left her after disclosing her status.
From the healthcare workers’ perspective, they reported that the whole process of HIV testing to treatment initiation was very quick, with women having to take a lot on in a small amount of time.
One healthcare worker commented, “We test her [a patient] today and she is found HIV positive, we immediately initiate her onto ART whilst she is still thinking about how she contracted the virus and she hasn’t yet accepted the reality about her serostatus, and we give her the drugs for her unborn child at the same time. So it’s like she is getting too much information at once before she makes the rightful decision.”
They also said that some women found out about their HIV status mid-labour and were immediately initiated on treatment – this introduction to ART at this late stage meant they associated pain with treatment and were unlikely to return to the clinic for follow-up.
Despite the benefits of Option B+ for getting women on treatment and infants on a prophylaxis to reduce their risk of HIV, health system barriers also hamper the delivery of Option B+, with healthcare workers saying a reoccurring lack of HIV testing kits and staff shortages was frustrating.
What is clear is that as more women access Option B+, novel and new interventions are needed to keep women in care, specifically addressing the challenges they face in the context. These could include the provision of Option B+ through peer-led interventions and giving women more of a say in their treatment delivery – in addition to interventions that target the health system.
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