Marriage as a risk factor for HIV: Learning from the experiences of HIV-infected women in Malawi

Abstract

The gender inequalities that characterise intimate partner relationships in Malawi, a country with one of the highest HIV prevalence rates in the world, arguably place marriage as an important risk factor for HIV infection among women, yet few studies detail the complex interactions of marriage and risk. In order to develop HIV-prevention interventions that have lasting impacts in such communities, we need a deeper understanding of the intricacies of women's lives, how and why they are involved in marital relationships, and the implications of these relationships for HIV transmission or prevention. This article describes how women understand marriage's effects on their lives and their HIV risks. Drawing from focus group discussions with 72 women attending antiretroviral clinics in Malawi, we explore why women enter marriage, what women's experiences are within marriage and how they leave spouses for other relationships. Based on their narratives, we describe women's lives after separation, abandonment or widowhood, and report their reflections on marriage after being married two or three times. We then review women's narratives in light of published work on HIV, and provide recommendations that would minimise the risks of HIV attendant on marriage.     

Assessing factors associated with HIV testing among adolescents in Malawi

Despite being at high risk of HIV/AIDS, most young people do not know their HIV status. Using survey data (n?=?2428) and applying multilevel models, this paper assesses factors associated with HIV testing among adolescents in Northern Malawi. The results show that among both boys (OR?=?0.39) and girls (OR?=?0.47), orphan status is associated with low likelihood of HIV testing. Correct knowledge about HIV/AIDS (OR?=?2.55) and having secondary education (OR?=?3.24) are associated with HIV testing among boys and girls, respectively. At the household level, living in a household whose head has secondary or higher education is positively associated with testing for boys (OR?=?2.63), while residing together with biological siblings predicts higher odds of testing (OR?=?2.67) for girls. Notably, orphaned girls’ disadvantage regarding HIV testing loses significance when residential arrangement is controlled. At the community level, having HIV testing facility (OR?=?2.70) or post-test club (OR?=?1.40) is positively associated with HIV testing for boys, while girls from areas where religious leaders hold judgmental views about HIV/AIDS are less likely (OR?=?0.45) to test. These findings suggest that efforts to scale up HIV testing among youth could benefit greatly from an understanding of how individual and community factors operate to influence adolescents to know their sero-status.     

HIV infection among paediatric in-patients in Blantyre, Malawi

To investigate the impact of HIV infection on hospital admission and death we studied children admitted to paediatric medical and surgical wards in Blantyre, Malawi, in March 2000. Unselected children whose parents or guardians consented to HIV testing of the child were recruited and HIV infection was determined by serology, with confirmation in children aged 15 months or less by PCR. We assessed the prevalence of HIV infection by age, clinical diagnosis and outcome of admission. Of 1064 admissions, 991 were tested for HIV infection, and 187 (18.9%) were infected. HIV was most common in children aged less than six months, 53 of 166 (32%). Parents of HIV-infected children were better educated, and more likely to have died, than those of uninfected children. Clinical symptoms and signs were not adequately sensitive or specific to be used for diagnosis of HIV. HIV was common in children with malnutrition (prevalence 40%), lower respiratory tract infection (29%) and sepsis (28%), and less prevalent among children with malaria (11%) or surgical admissions (11%). Almost 30% of HIV-infected children died, compared with 8.9% of uninfected children, and HIV-infected children constituted over 40% of in-patient deaths.     

The effect of marriage and HIV risks on condom use acceptability in rural Malawi

A large and increasing proportion of HIV transmissions in sub-Saharan Africa occur within marriage. Condom use within marriage could, therefore, be an important prevention strategy, but there is considerable debate about whether married couples would be willing to use condoms. This paper contributes to this debate by identifying key factors that affect the acceptability of condom use within marriage and actual condom use among men and women in rural Malawi, using three waves of longitudinal data from 2004, 2006 and 2008. Specifically, we focused on the effect of (1) entry into first marriage, (2) respondent's HIV status, HIV perceptions, and risk behaviors, and (3) spouse's HIV characteristics on condom use acceptability within marriage and actual condom use with a spouse or steady partner. Using fixed-effects regression, we found that getting married coincides with a pronounced attitudinal shift regarding the acceptability of condom use within marriage that cannot be explained by differences in fertility status or selection into marriage. In addition, we found that, for women, perceived HIV status of the respondent and spouse generally had greater influence than actual HIV status on the acceptability of condom use within marriage and actual condom use with a spouse or steady partner, even after HIV status is known; while actual HIV status and HIV risk behaviors are generally more important among men. Although condom use within marriage remained low, these findings suggest that attitudes about and use of condoms are susceptible to change and that both marital status and perceptions of risk are important influences on condom use.     

Perceptions of voluntary medical male circumcision among circumcising and non-circumcising communities in Malawi

Three randomised controlled trials in Africa indicated that voluntary medical male circumcision (VMMC) is an effective method to reduce a man's risk of becoming infected through sex with an HIV-positive female partner. The success of recent public health initiatives to increase numbers of circumcised men in Malawi has been very limited. We conducted in-depth interviews and focus group discussions (FGDs) with men, women and male adolescents from non-circumcising and circumcising communities in southern Malawi to better understand their beliefs about male circumcision and the promotion of VMMC for HIV prevention. Results revealed that beliefs about male circumcision, in general, are strongly mediated by Malawian culture and history. Participants have attempted to develop a new meaning for circumcision in light of the threat of HIV infection and the publicised risk reduction benefits of VMMC. Several study participants found it difficult to distinguish VMMC from traditional circumcision practices (jando and lupanda), despite awareness that the new form of circumcision was an expression of (western) modern medicine performed largely for public health purposes. Greater recognition of background cultural beliefs and practices could inform future efforts to promote medical male circumcision as an HIV prevention strategy in this context.     

Concern and practice among men about HIV/AIDS in low socioeconomic income areas of Lilongwe, Malawi

The HIV prevalence rate in Malawi, currently estimated to be 15%, is among the highest in the world. There is a growing realization that in order to understand the underlying causes and devise more effective prevention strategies focus should be placed on economic, political, social, and cultural forces as well as perceptions of individual risk to HIV/AIDS. During 2003 we conducted field work in Lilongwe, the capital city of Malawi, to examine perceptions of individuals as to their risk to HIV infection using the structured interviews and the focus group discussions with men from five areas of Lilongwe. The discussion in this paper focuses on the perception of risk to HIV infection among men in low socioeconomic income areas that we interviewed. Our findings indicate that while knowledge about HIV/AIDS and the best ways in which one can protect oneself from getting HIV is very high, people continue to engage in at-risk behaviors without using the necessary protection. Many of the men in our sample indicated that they were indeed at risk of getting infected with HIV. In spite of this, some of the respondents in both the structured interviews and the focus group discussions pointed out that some people had began taking measures to protect themselves, such as using condoms with nonregular partners, women leaving their husbands where cheating was obvious, and, for men, reducing the number of extra-marital sexual relations.     

Changing attitudes and beliefs towards a woman’s right to protect against HIV risk in Malawi

Female empowerment and positive attitudes towards women’s rights in sexual relationships have been found to be key elements of successful behaviour-based HIV prevention programmes. However, HIV prevention programmes that do not specifically engage with gender issues may also affect attitudes and beliefs towards women’s rights within sexual relationships. Using data from the Malawi Longitudinal Study of Families and Health we compare measures of female empowerment and changing gender norms between intervention participants and non-participants. Results suggest that female intervention participants were more likely than non-participants to believe that: (1) women have more rights within sexual relationships in general and (2) women have the right to protect themselves against HIV risk (indicating possible increases in female self-efficacy in making HIV prevention decisions). Male intervention participants showed no substantial positive change in attitudes towards women’s rights. These results highlight an important positive effect of HIV prevention programmes on women’s attitudes towards their own rights.     

Decline in adverse outcomes and death in tuberculosis patients in Malawi: association with HIV interventions

Between 2000 and 2012, the annual numbers of patients treated for tuberculosis (TB) in Malawi declined by 28%, from 28 234 to 20 463. During this time, the proportion of TB patients tested for the human immunodeficiency virus (HIV) increased from 6% to 87%. Most HIV-infected patients received cotrimoxazole preventive therapy, and the proportion receiving antiretroviral therapy increased to 88%. Between 2000 and 2008 there was a significant decline in all adverse outcomes (from 31% to 14%), and particularly in deaths (from 23% to 10%) and loss to follow-up (from 5.2% to 1.9%, P < 0.001). After 2008, there was no decrease in any adverse outcome. Ways to further reduce TB-associated mortality are discussed.     

Antiretroviral therapy for children in the routine setting in Malawi

Malawi is scaling up antiretroviral therapy (ART) for HIV-infected patients. Using a fixed-dose combination of stavudine+lamivudine+nevirapine ('Triomune') as the first-line regimen, split tablets are given to children with doses according to body weight. By March 2006, a total of 46 702 patients had been started on ART, of whom 2718 (5.8%) were children aged <15 years. In a subset of 935 children, comprising 486 boys and 449 girls, 1.5% were aged <1 year, 26% were aged 1-4 years, 39% were aged 5-9 years and 33% were aged 10-14 years. Between July and September 2005, 7905 patients started ART, comprising 7469 adults and 436 children. Six-month cohort outcomes censored on 31 March 2006 showed significantly more children alive and significantly fewer children dead or defaulted compared with adults. Between January and March 2005, 4580 patients started ART, comprising 4347 adults and 233 children. Twelve-month cohort outcomes censored on 31 March 2006 showed significantly more children alive compared with adults. The results of this national study should encourage other programmes to invest in ART for children and particularly to monitor their treatment outcomes.     

Prevalence and indicators of HIV and AIDS among adults admitted to medical and surgical wards in Blantyre,Malawi

Despite high seroprevalence there are few recent studies of the effect of human immunodeficiency virus (HIV) on hospitals in sub-Saharan Africa. We examined 1226 consecutive patients admitted to medical and surgical wards in Blantyre, Malawi during two 2-week periods in October 1999 and January 2000: 70% of medical patients were HIV-positive and 45% had acquired immune deficiency syndrome (AIDS); 36% of surgical patients were HIV-positive and 8% had AIDS. Seroprevalence rose to a peak among 30-40 year olds; 91% of medical, 56% of surgical and 80% of all patients in this age group were HIV-positive. Seropositive women were younger than seropositive men (median age 29 vs. 35 years, P < 0.0001). Symptoms strongly indicative of HIV were history of shingles, chronic diarrhoea or fever or cough, history of tuberculosis (TB), weight loss and persistent itchy rash (adjusted odds ratios [AORs] all > 5). Clinical signs strongly indicative of HIV were oral hairy leukoplakia, shingles scar, Kaposi's sarcoma, oral thrush and hair loss (AORs all > 10). Of surgical patients with 'deep infections' (breast abscess, pyomyositis, osteomyelitis, septic arthritis and multiple abscesses), 52% were HIV-positive (OR compared with other surgical patients = 2.4). Severe bacterial infections, TB and AIDS caused 68% of deaths. HIV dominates adult medicine, is a major part of adult surgery, is the main cause of death in hospital and affects the economically active age group of the population.     

Cultural Norms and Risk: Lessons Learned from HIV in Thailand

Cultural sensitivity has been identified as an important component of assessment and intervention for HIV risk. Recognizing cultural norms is important for selecting methods for assessment and intervention. The behavioral HIV literature in Thailand is reviewed to illustrate the importance of the localization of cultural norms and practices, the often fragmented or mediated character of broad social dynamics, and subtleties of drawing cross-cultural inferences. We also discuss the implications of cultural norms for selecting research methods and highlight the importance of participatory research approaches for adequately capturing and incorporating cultural elements in the design of assessments and interventions.     

Monitoring the response to antiretroviral therapy in resource-poor settings: the Malawi model

With assistance from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), Malawi is scaling-up the delivery of antiretroviral (ARV) therapy to HIV-positive eligible patients. The country has developed National ARV Treatment Guidelines, which emphasize a structured and standardized approach for all aspects of ARV delivery, including monitoring and evaluation. Using the successful DOTS model adapted by National TB Control Programmes throughout the world, Malawi has developed a system of quarterly ARV cohort and cumulative ARV quarterly analyses. Thyolo district, in the southern region of Malawi, has been using this system since April 2003. This paper describes the standardized ARV treatment regimens and the treatment outcomes used in Thyolo to assess the impact of treatment, the registration and monitoring systems and how the cohort analyses are carried out. Data are presented for case registration and treatment outcome for the first quarterly cohort (April to June) and the combined cohorts (April to June and July to September). Such quarterly analyses may be useful for districts and Ministries of Health in assessing ARV delivery, although the burden of work involved in calculating the numbers may become large once ARV delivery systems have been established for several years.     

Community support is associated with better antiretroviral treatment outcomes in a resource-limited rural district in Malawi

A study was carried in a rural district in Malawi among HIV-positive individuals placed on antiretroviral treatment (ART) in order to verify if community support influences ART outcomes. Standardized ART outcomes in areas of the district with and without community support were compared. Between April 2003 (when ART was started) and December 2004 a total of 1634 individuals had been placed on ART. Eight hundred and ninety-five (55%) individuals were offered community support, while 739 received no such support. For all patients placed on ART with and without community support, those who were alive and continuing ART were 96 and 76%, respectively (P<0.001); death was 3.5 and 15.5% (P<0.001); loss to follow-up was 0.1 and 5.2% (P<0.001); and stopped ART was 0.8 and 3.3% (P<0.001). The relative risks (with 95% CI) for alive and on ART [1.26 (1.21-1.32)], death [0.22 (0.15-0.33)], loss to follow-up [0.02 (0-0.12)] and stopped ART [0.23 (0.08-0.54)] were all significantly better in those offered community support (P<0.001). Community support is associated with a considerably lower death rate and better overall ART outcomes. The community might be an unrecognized and largely 'unexploited resource' that could play an important contributory role in countries desperately trying to scale up ART with limited resources.     

Accessing ART in Malawi while living in South Africa – a thematic analysis of qualitative data from undocumented Malawian migrants

The majority of international migrants from Malawi to South Africa are undocumented, and some of them are on ART. This study explored how these migrants manage to access ART. Qualitative data were collected using open-ended questions in semi-structured interviews. 23 returned undocumented Malawian migrants from South Africa participated in the study. Also, key informant discussions were held with three health workers. Data collection took place in April and May 2015 at a rural village of Namwera in Mangochi district in southern Malawi. Interviews were audio-recorded, transcribed and translated into English for thematic analysis. The guardians collected ART from health facilities in Malawi on behalf of the migrants. The guardians sent ART through truck and bus drivers to the migrants in South Africa. The migrants shared their ART. Others bought ART from the ‘street pharmacies’. Others accessed ART from South African health facilities through the help of their South African friends. There are risks to dispensing ART to the migrants who do not themselves present at health facilities. There is value to more regular contacts between clients and health service system that is compromised by alternative strategies. It is better to deliver ART services in South Africa to the undocumented migrants.     

A patient infected with HIV as a result of intravenous drug misuse

This case study demonstrates that the stereotype image of drug users as being non-compliant and uncaring about their health is not always correct. This article demonstrates that it is possible to promote weight gain in a patient infected with HIV as a result of intravenous drug misuse with a rather chaotic, addictive life-style.
This patient gained a significant amount of weight, even after being diagnosed as suffering from AIDS 3 years previously, and continues to maintain his weight and have relatively few medical problems.     

Targeting CD4 testing to a clinical subgroup of patients could limit unnecessary CD4 measurements, premature antiretroviral treatment and costs in Thyolo District, Malawi

Malawi offers antiretroviral treatment (ART) to all HIV-positive adults who are clinically classified as being in WHO clinical stage III or IV without 'universal' CD4 testing. This study was conducted among such adults attending a rural district hospital HIV/AIDS clinic (a) to determine the proportion who have CD4 counts >or=350 cells/microl, (b) to identify risk factors associated with such CD4 counts and (c) to assess the validity and predictive values of possible clinical markers for CD4 counts >or=350 cells/microl. A CD4 count >or=350 cells/microl was found in 36 (9%) of 401 individuals who are thus at risk of being placed prematurely on ART. A body mass index (BMI) >22 kg/m(2), the absence of an active WHO indicator disease at the time of presentation for ART, and a total lymphocyte count >1,200 cells/microl were significantly associated with such a CD4 count. The first two of these variables could serve as clinical markers for selecting subgroups of patients who should undergo CD4 testing. In a resource-limited district setting, assessing the BMI and checking for active opportunistic infections are routine clinical procedures that could be used to target CD4 measurements, thereby minimising unnecessary CD4 measurements, unnecessary (too early) treatment and costs.