Addressing the Blind Spot in Achieving Epidemic Control in Malawi: Implementing "male-friendly" HIV services to increase access and uptake

What was the problem?

In Malawi, men living with HIV (MLHIV) are less likely than their female counterparts to be aware of their HIV status, to be on antiretroviral treatment (ART) and to be virally suppressed. As a result, men are more likely to die of HIV-related causes. Some of the barriers experienced by men relate to access to HIV services, which are typically provided during working hours in congested facilities, and insufficient information about the importance of knowing your status and initiating ART early. Additionally, men may have perceptions of stigma when accessing HIV testing services through maternal and child health service (MCH) platforms.

What is the solution?

To address barriers that prevent men from accessing services, a differentiated service delivery model for men was designed and implemented as a demonstration project by the Elizabeth Glazer Pediatric AIDS Foundation (EGPAF). The demonstration project was conducted in referral hospitals located in rural settings. Male-friendly clinics provide integrated HIV, reproductive health, and non-communicable disease (NCD) services during times that are more suitable for men; in this case, on Saturdays from 7:30 am-2:00 pm. EGPAF designed “male-friendly” services with input from MLHIV with male clinicians providing the services. To minimize stigma, men reported that integrating services for NCDs (specifically hypertension and diabetes screening) was important. The Malawi Ministry of Health (MoH) already provide these services, so this represented a change in service flow rather than the introduction of new services.

What was the impact?

At the three pilot male-friendly clinics, EGPAF supported health workers to offer provider-initiated testing and counseling (PITC) in addition to routine screening for sexually transmitted infections (STIs), hypertension, and diabetes on Saturdays. EGPAF reported that from May-December 2017, 1,827 men attended the male-friendly clinics at the three pilot sites, representing a mean of 228 male clients per month.

Of the 1,827 male clients attending (May to December 2017),

  • 1,294 were eligible for testing,

  • 94 percent (1216/1294) of clients received HIV testing, and

  • 61 new positives were identified, representing an HIV positivity rate of 5 percent. 

Ninety-five percent (95 percent) of the newly-identified HIV-positive clients were initiated on ART, with 56 percent (34/61) starting on ART on the same day. General health screenings identified that of the 1,827 male clients attending male-friendly clinics, 0.8 percent were diagnosed as new diabetics and 3.2 percent were newly identified as hypertensive. Of the male clients screened for STIs, an estimated 6 percent (104/ 1735) were new STI cases.

There is variation across the districts in the HIV positivity rates of men tested at the male-friendly clinics. While the national average HIV positivity rate is 3.1 percent (MOH, 2017), the mean HIV positivity rate at male-friendly clinics is 5 percent. Figure 2 below also demonstrates the variability in yield among age groups, with men ages 35-39 having the highest HIV positivity rate of men tested at male-friendly clinics.

Figure 2. High yields in target population of men over 25 years of age.

Figure 2. High yields in target population of men over 25 years of age.

How does it work?

INDIVIDUAL LEVEL

From literature reviews, some of the barriers experienced by men relate to access and acceptability of HIV service delivery:

  • There is anecdotal evidence that services may not be provided in an environment that is conducive to men’s needs

  • Few health services that men routinely access are integrated with HIV testing. In contrast to men, women in the sexual and reproductive age group routinely access provider initiated testing and counselling through MCH service platforms at facility and community level

  • Men may not want to access HIV testing services through MCH platforms because they are embarrassed to be in a perceived “female space”

  • Due to limited contact with health services, men also may have lower health literacy levels in comparison to women who receive health education messages more frequently

  • Providers offer HIV services during working hours and clients may experience long waiting times at congested facilities

Male-friendly clinics are designed to address these barriers.

SERVICE DELIVERY LEVEL

The EGPAF intervention package was initially piloted in three district hospitals in Mchinji, Ntcheu, and Dedza. Although these three districts are rural, the district hospitals are located in areas with trading centers and hot spots for HIV transmission. Male-friendly clinics were open on Saturdays from 7:30 am – 2:00 pm. These services are exclusively for men and are also run by male providers. They include HIV testing services, ART and screening and management of STIs and NCD (hypertension and diabetes) leveraging existing programs. Health services are provided free of charge to the patient in these settings. To increase awareness of the services provided at male-friendly clinics, health education advice is provided during routine outpatient service delivery. EGPAF conducted sensitization and mobilization through local radio stations and community announcements so that men in the community were aware of the male-friendly clinics.

The table below describes staffing at each male-friendly clinic.

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LOCAL ENVIRONMENT

EGPAF obtained feedback from men attending routinely available services to refine components of the service delivery model. These included male clients attending other health services for various reasons prior to the implementation of the male-friendly clinics. EGPAF’s engagement with the District Health Management Team in each district shaped the male-friendly clinic’s design and enabled the integration of the services at MoH sites. Based on feedback from the male clients, integration of multi-disease screening services and the male-friendly environment seem to be critical components of the appeal of this service delivery model. Attending a clinic with male health care workers and with a waiting area exclusively for men has made men more open to the idea of seeking screening services at the hospital.

NATIONAL ENVIRONMENT

At a national level, the National Strategic Plan for HIV and TB promoted the need for innovating HIV case identification strategies that are tailored to serve the needs of men. MPHIA data further highlighted the need for testing and treatment approaches that address the bottlenecks limiting men’s access to HIV services. In response, the MOH’s HIV Department established a sub-committee to identify differentiated care models. This group is advocating for the scale-up of male-friendly health services. The scope of this sub-committee has since expanded to include the development of operational guidance. EGPAF’s experience with implementation will inform this guidance.

SCALE UP

Male-friendly services have been scaled up from an initial three pilot sites in May 2017 to 25 sites as of October 2018 in EGPAF-supported districts. The site selection is based on a facility’s physical space availability to run a dedicated clinic with HIV services and operational NCD programs supported through the MoH. No additional staff were recruited to provide services. Although the pilot sites were conducted in hospitals this model has also been rolled out to health centers.