Date Published: March 21, 2019
Publisher: Public Library of Science
Author(s): Natalie Jean Tibbels, Zoé Mistrale Hendrickson, Danielle Amani Naugle, Abdul Dosso, Lynn Van Lith, Elizabeth C. Mallalieu, Anne Marie Kouadio, Walter Kra, Diarra Kamara, Patricia Dailly-Ajavon, Adama Cisse, Kim Seifert-Ahanda, Sereen Thaddeus, Stella Babalola, Christopher J. Hoffmann, Jerome T. Galea.
Men in sub-Saharan Africa have lower rates of HIV testing and are less likely to initiate treatment compared to women. Service delivery dimensions are a key factor in facilitating engagement along the HIV treatment continuum for men and women, yet male specific overall perceptions of the service delivery environment have received little attention in West Africa. This study draws on qualitative data collected in Côte d’Ivoire to explore provider-level and structural factors affecting men’s engagement in HIV testing and treatment through interviews and focus group discussions conducted with health workers and men living with HIV (some on ART) or whose HIV status was unknown. Factors influencing decisions to test or initiate treatment were considered in terms of perceived benefits and costs. Men described costs at the interpersonal (client-provider) level, such as unwanted disclosure or stigma, which were weighed against the potential for social support and clinical guidance. Likewise, fear of unwanted disclosure operated at the facility level, as the layout of facilities sometimes grouped clients living with HIV together. Notably, the benefits men described from engaging in HIV testing and care all operated at the interpersonal level and none at the facility level. In light of the fact that provider- and facility-level factors influenced the perceptions and experiences of men along the treatment continuum, we offer recommendations to reduce barriers to testing and engagement in care related to service delivery.
Côte d’Ivoire is one of 35 priority countries identified by the World Health Organization that account for 90% of new HIV infections globally and have been giving specific transmission, testing, and treatment targets . Côte d’Ivoire has one of the highest HIV-prevalence rates in West Africa with 2.8% of adults of reproductive age (15–49) living with HIV . Though AIDS-related deaths have declined considerably in the past 15 years, universal access to HIV treatment is considered necessary to end the epidemic[3,4]. To accelerate the global decline in AIDS-related deaths, the Joint United Nations Programme on HIV/AIDS established the 90-90-90 targets: by 2020, 90% of people living with HIV will know their HIV status, 90% of people diagnosed with HIV will receive sustained antiretroviral therapy (ART), and 90% of people receiving ARTs will achieve viral suppression . If the 90-90-90 target is met, AIDS related deaths globally are expected to decline from one million in 2016 to fewer than 500,000 in 2020  and new HIV infections in Côte d’Ivoire could be reduced by 50% by 2030 . Throughout sub-Saharan Africa, a higher proportion of women than men undergo HIV testing and a higher proportion of women living with HIV have been diagnosed and are on ART . For example, in Cote d’Ivoire, 60% of women living with HIV aged 15 or older compared to 29% of their male counterparts are on ART . In addition, following diagnosis, men are less likely to link to care, achieve viral load suppression, or survive[7–9]. Men have particularly low levels of testing, with 75% of men (vs. 62% of women) unaware of their HIV status . In light of the difference in outcomes between men and women, population-specific approaches to improving outcomes among men are warranted, including strategies to improve the continuum of HIV care among men .
To explore provider- and facility-level factors that affected men’s engagement along the HIV continuum of care, we explored men’s perspectives from data collected as part of a larger formative qualitative study. As part of that study, men’s perceptions and values were sought through in-depth interviews (IDIs) and focus-group discussions (FGDs) conducted in three urban areas in Côte d’Ivoire: Abidjan, Bouaké, and San Pedro. The research protocol and instruments were approved by the Johns Hopkins Bloomberg School of Public Health (JHSPH) Institutional Review Board [IRB#00007374] and the local ethics committee (Comité National d’Ethique de la Recherche) in Côte d’Ivoire. Written informed consent was obtained from all participants prior to data collection.
Across three sites, 227 adult men participated in the study. Four men recruited to the study chose not to participate; no participants dropped out of the study. The sample contained a higher proportion of men in the older age category (57 men aged 35 to 49 vs. 44 men 25 to 34), and 28 were known to be living with HIV. Table 1 summarizes the distribution of participants across age, roles, interview type, and HIV status.
Several key insights emerged in men’s perceptions of, and experiences with, clinicians and clinics in regard to HIV testing and HIV care. Both MLHIV not in treatment and men with unknown HIV status were concerned about mistreatment or confidentiality breaches by providers. Clinic procedures were seen as potentially leading to inadvertent disclosure through being seen at the clinic or in a queue for HIV services. Providers were seen as posing risks for disclosure or enacted stigma to many men, especially those not diagnosed or not yet in care. Provider interactions sometimes had the added psychosocial benefit. This highlights a dichotomy between anticipated negative experiences among men not engaged in HIV care in our study and lived, generally positive, experiences among men engaged in care.