A Social Ecological Approach to Exploring Barriers to Accessing Sexual and Reproductive Health Services among Couples Living with HIV in Southern Malawi
With wide access to antiretroviral therapy, people living with HIV are living longer. The reduction in the mother-to-child transmission of HIV has encouraged some people living with HIV to have children and remarry. However, some continue to have limited access to sexual and reproductive health services. The study explores barriers encountered by couples living with HIV in accessing sexual and reproductive health services using the social ecological model. Data were collected using in-depth interviews with twenty couples purposively sampled in matrilineal Chiradzulu and patrilineal Chikhwawa communities in Malawi from July to December 2010. Data were analyzed using framework analysis method. The study findings identify barriers across the five levels of the social ecological model indicating that the use of sexual and reproductive health services is influenced by diverse factors. We suggest three main areas for primary intervention: services must be located closer to their communities and integrated with existing antiretroviral services. In addition, information gatekeepers, both formal and informal, should be empowered with knowledge about sexual and reproductive health, including HIV and AIDS. Finally, there is a need to coordinate the flow of reproductive health, HIV, and AIDS information between Malawi Ministry of Health and formal and informal organizations. 1. Introduction HIV remains a challenge to public health in Africa. Recent data indicate that the rate of new HIV infections has decreased; for instance, in 33 countries, HIV incidence has fallen by more than 25% between 2001 and 2009 [1]. Of these countries, 22 are in Sub-Saharan Africa. However, there are still 22.5 million adults and children living with HIV. Heterosexual contact is the principal mode of transmission seconded by mother-to-child transmission of HIV [1]. With the advent of antiretroviral therapy (ART/ARV), worldwide health improvements have occurred over the last decades and the result has been a dramatic reduction in HIV-related morbidity and mortality, and improvements in quality of life [2–5]. HIV infection may now be considered a chronic illness because the ARVs suppress HIV replication thereby increasing CD4 cell count, delaying clinical progression of AIDS and prolonging survival [6]. Similarly, the number of people living with HIV (PLWH) is increasing due to decreased mortality because of ART [1]. Similar situations have been noted in earlier studies in developed countries such as France, Brazil, and the United States of America [5, 7, 8]. With a broader spectrum of
References
[1]
“Joint United Nations Programme on HIV/AIDS (UNAIDS),” Global Report: Report on the Global AIDS Epidemic, Geneva, Switzerland, 2010.
[2]
D. Cooper, J. Harries, L. Myer, P. Orner, H. Bracken, and V. Zweigenthal, “Life is still going on: reproductive intentions among HIV-positive women and men in South Africa,” Social Science and Medicine, vol. 65, no. 2, pp. 274–283, 2007.
[3]
R. Isingo, B. Zaba, M. Marston et al., “Survival after HIV infection in the pre-antiretroviral therapy era in a rural Tanzanian cohort,” AIDS, vol. 21, supplement 6, pp. S5–S13, 2007.
[4]
T. Kredo, J. S. Van der Walt, N. Siegfried, and K. Cohen, “Therapeutic drug monitoring of antiretrovirals for people with HIV,” Cochrane Database Systematic Review, vol. 8, no. 3, p. CD007268, 2009.
[5]
V. Paiva, N. Santos, I. Fran？a-Junior, E. Filipe, J. R. Ayres, and A. Segurado, “Desire to have children: gender and reproductive rights of men and women living with HIV: a challenge to health care in Brazil,” AIDS Patient Care and STDs, vol. 21, no. 4, pp. 268–277, 2007.
[6]
J. E. Gallant, “Strategies for long-term success in the treatment of HIV infection,” Journal of the American Medical Association, vol. 283, no. 10, pp. 1329–1334, 2000.
[7]
S. Attia, M. Egger, M. Müller, M. Zwahlen, and N. Low, “Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis,” AIDS, vol. 23, no. 11, pp. 1397–1404, 2009.
[8]
I. Heard, R. Sitta, F. Lert et al., “Reproductive choice in men and women living with HIV: evidence from a large representative sample of outpatients attending French hospitals (ANRS-EN12-VESPA study),” AIDS, vol. 21, no. 1, pp. S77–S82, 2007.
[9]
L. T. Matthews and J. S. Mukherjee, “Strategies for harm reduction among HIV-affected couples who want to conceive,” AIDS and Behavior, vol. 13, no. 1, pp. S5–S11, 2009.
[10]
K. Peltzer, L. W. Chao, and P. Dana, “Family planning among HIV positive and negative prevention of mother to child transmission (PMTCT) clients in a resource poor setting in South Africa,” AIDS and Behavior, vol. 13, no. 5, pp. 973–979, 2009.
[11]
C. S. Chasela, M. G. Hudgens, D. J. Jamieson et al., “Maternal or infant antiretroviral drugs to reduce HIV-1 transmission,” The New England Journal of Medicine, vol. 362, no. 24, pp. 2271–2281, 2010.
[12]
S. Kanniappan, M. J. Jeyapaul, and S. Kalyanwala, “Desire for motherhood: Exploring HIV-positive women's desires, intentions and decision-making in attaining motherhood,” AIDS Care, vol. 20, no. 6, pp. 625–630, 2008.
[13]
V. Agadjanian and S. R. Hayford, “PMTCT, HAART, and childbearing in Mozambique: an institutional perspective,” AIDS and Behavior, vol. 13, supplement 1, pp. S103–S112, 2009.
[14]
I. F. Hoffman, F. E. A. Martinson, K. A. Powers et al., “The year-long effect of HIV-positive test results on pregnancy intentions, contraceptive use, and pregnancy incidence among Malawian women,” Journal of Acquired Immune Deficiency Syndromes, vol. 47, no. 4, pp. 477–483, 2008.
[15]
T. Newmeyer, S. Tecimer, D. Jaworsky, S. Chihrin, K. Gough, A. Rachlis, et al., “Case series of fertility treatment in HIV-discordant couples (male positive, female negative): the Ontario Experience,” PLoS ONE, vol. 6, no. 9, Article ID e24853, 2011.
[16]
S. Russell and J. Seeley, “The transition to living with HIV as a chronic condition in rural Uganda: working to create order and control when on antiretroviral therapy,” Social Science and Medicine, vol. 70, no. 3, pp. 375–382, 2010.
[17]
National Statistical Office, “Malawi demographic and health survey 2010,” Tech. Rep., Zomba, Malawi, 2010.
[18]
World Health Organization, Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV-Infection in Infants. Recommendations for a Public Health Approach, Geneva, Switzerland, 2010.
[19]
M. Berer, “HIV/AIDS, sexual and reproductive health: intimately related,” Reproductive Health Matters, vol. 11, no. 22, pp. 6–11, 2003.
[20]
S. Gruskin, L. Ferguson, and J. O'Malley, “Ensuring sexual and reproductive health for people living with HIV: an overview of key human rights, policy and health systems issues,” Reproductive Health Matters, vol. 15, supplement 29, pp. 4–26, 2007.
[21]
M. Collumbien, J. Busza, J. Cleland, and O. Campbell, Social Science Methods for Research on Sexual and Reproductive Health, WHO, Geneva, Switzerland, 2012.
[22]
D. Stokols, “Translating social ecological theory into guidelines for community health promotion,” American Journal of Health Promotion, vol. 10, no. 4, pp. 282–298, 1996.
[23]
J. P. Elder, L. Lytle, J. F. Sallis et al., “A description of the social-ecological framework used in the trial of activity for adolescent girls (TAAG),” Health Education Research, vol. 22, no. 2, pp. 155–165, 2007.
[24]
J. Sallis and N. Owen, “Ecological models of health behaviour,” in Health Behaviour and Health Education: Theory, Research and Practice, K. Glanz, B. Rimer, and F. Lewis, Eds., pp. 462–484, San Francisco, Calif, USA, 3rd edition, 2002.
[25]
E. Reifsnider, M. Gallagher, and B. Forgione, “Using ecological models in research on health disparities,” Journal of Professional Nursing, vol. 21, no. 4, pp. 216–222, 2005.
[26]
A. M. Chimbiri, “The condom is an 'intruder' in marriage: evidence from rural Malawi,” Social Science and Medicine, vol. 64, no. 5, pp. 1102–1115, 2007.
[27]
P. E. Peters, “Against the odds. Matriliny, land and gender in the shire highlands of Malawi,” Critique of Anthropology, vol. 17, no. 2, pp. 189–210, 1997.
[28]
A. Kuzel, “Sampling in qualitative inquiry,” in Doing Qualitative Research, B. Crabtree and W. Miller, Eds., pp. 31–44, Sage, Newbury Park, Calif, USA, 1992.
[29]
R. Emerson, R. Fretz, and L. Shaw, Writing Ethnographic Fieldnotes, chapter 5, The University of Chicago, London, UK, 1995.
[30]
J. Morse and L. Richards, Readme First for a User’s Guide to Qualitative Methods, Sage, London, UK, 2nd edition, 2007.
[31]
C. Pope, S. Ziebland, and N. Mays, “Analysing qualitative data,” British Medical Journal, vol. 320, no. 7227, pp. 114–116, 2000.
[32]
T. Delvaux and C. N？stlinger, “Reproductive choice for women and men living with HIV: contraception, abortion and fertility,” Reproductive Health Matters, vol. 15, no. 29, pp. 46–66, 2007.
[33]
S. Merkel, J. Otai, L. Archer, and P. Lynam, “Making comprehensive care for HIV a reality in African Urban Slums.,” Baltimore, Jhpiego, http://www.jhpiego.org/files/UrbanSlums_Comprehensive_Care.pdf, 2008.
[34]
R. Fabienne, D. Hercot, C. Quédraogo, T. Delvaux, S. Samaké, J. van Olmen, et al., “Sub-Saharan Africa and the health MDGs: the need to move beyond the "quick impact" model,” Reproductive Health Matters, vol. 19, no. 38, pp. 42–55, 2011.
[35]
D. Cooper, J. Moodley, V. Zweigenthal, L. G. Bekker, I. Shah, and L. Myer, “Fertility intentions and reproductive health care needs of people living with HIV in Cape Town, South Africa: implications for integrating reproductive health and HIV Care services,” AIDS and Behavior, vol. 13, no. 1, pp. S38–S46, 2009.
[36]
J. Beyeza-Kashesya, F. Kaharuza, F. Mirembe, S. Neema, A. M. Ekstrom, and A. Kulane, “The dilemma of safe sex and having children: challenges facing HIV sero-discordant couples in Uganda,” African Health Sciences, vol. 9, no. 1, pp. 2–12, 2009.
[37]
A. A. Nóbrega, F. A. S. Oliveira, M. T. G. Galv？o et al., “Desire for a child among women living with HIV/AIDS in northeast Brazil,” AIDS Patient Care and STDs, vol. 21, no. 4, pp. 261–267, 2007.
[38]
T. Lindgren, K. Deutsch, E. Schell et al., “Using mobile clinics to deliver HIV testing and other basic health services in rural Malawi,” Rural and Remote Health Journal, vol. 11, no. 2, p. 1682, 2011.
[39]
D. Romer, S. Sznitman, R. DiClemente et al., “Mass media as an HIV-prevention strategy: using culturally sensitive messages to reduce HIV-associated sexual behavior of at-risk African American youth,” American Journal of Public Health, vol. 99, no. 12, pp. 2150–2159, 2009.
[40]
E. Rogers, Diffusion of Innovations, Free Press, New York, NY, USA, 5th edition, 2003.
[41]
J. Foreit and S. Raifman, Increasing Access to Family Planning (FP) and Reproductive Health (RH) Services Through Task-Sharing between Community Health Workers (CHWs) and Community Mid-Level Professionals in Large-Scale Public-sector Programs: a Literature Review to Help Guide Case Studies, 2011.
[42]
K. Viswanathan, P. Hansen, M. Rahman, L. Steinhardt, A. Edward, S. Arwal, et al., “Can community health workers increase coverage of reproductive health services?” Journal of Epidemiology & Community Health, vol. 66, no. 10, 2011.
[43]
WHO, Task Shifting: Global Recommendations and Guidelines, World Health Organization, Geneva, Switzerland, 2008.
[44]
R. Zachariah, N. Ford, M. Philips et al., “Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub-Saharan Africa,” Transactions of the Royal Society of Tropical Medicine and Hygiene, vol. 103, no. 6, pp. 549–558, 2009.
[45]
J. Sherwani, S. Palijo, S. Mirza, T. Ahmed, N. Ali, and R. Rosenfeld, “Speech vs. touch-tone: telephony interfaces for information access by low literate users,” in Proceedings of the International Conference on Information and Communication Technologies and Development (ICTD '09), pp. 447–457, April 2009.
[46]
L. A. Kamwendo, “Childbirth experiences in Malawi,” Childbirth Across Cultures, vol. 5, pp. 235–244, 2009.
[47]
A. C. Munthali and E. M. Zulu, “The timing and role of initiation rites in preparing young people for adolescence and responsible sexual and reproductive behaviour in Malawi,” African Journal of Reproductive Health, vol. 11, no. 3, pp. 150–167, 2007.
[48]
T. Veinot, R. Harris, L. Bella, I. Rootman, and J. Krajnak, “HIV/AIDS information exchange in rural communities: preliminary findings from a three-province study,” Canadian Journal of Information and Library Science, vol. 30, no. 3-4, pp. 271–290, 2006.
[49]
Ministry of Health, Prevention of Mother To Child Transmission of HIV and Paediatric HIV Care Guidelines, Lilongwe, Malawi, 2008.
[50]
S. Yeatman, “‘HIV is an enemy of childbearers’: the construction of local epidemiology in rural Malawi,” Culture, Health and Sexuality, vol. 13, no. 4, pp. 471–483, 2011.
[51]
Ministry of Health, National Sexual and Reproductive Health and Rights (SRHR) Policy, Lilongwe, Malawi, 2009.
[52]
F. Kasenga, P. Byass, M. Emmelin, and A. K. Hurtig, “The implications of policy changes on the uptake of a PMTCT programme in rural Malawi: first three years of experience,” Global Health Action, vol. 2, p. 1883, 2009.
[53]
J. Harries, D. Cooper, L. Myer, H. Bracken, V. Zweigenthal, and P. Orner, “Policy maker and health care provider perspectives on reproductive decision-making amongst HIV-infected individuals in South Africa,” BMC Public Health, vol. 7, p. 282, 2007.
[54]
P. Orner, D. Cooper, L. Myer, V. Zweigenthal, L. G. Bekker, and J. Moodley, “Clients' perspectives on HIV/AIDS care and treatment and reproductive health services in South Africa,” AIDS Care, vol. 20, no. 10, pp. 1217–1223, 2008.
[55]
P. Oosterhoff, N. T. Anh, N. T. Hanh, P. N. Yen, P. Wright, and A. Hardon, “Holding the line: Family responses to pregnancy and the desire for a child in the context of HIV in Vietnam,” Culture, Health and Sexuality, vol. 10, no. 4, pp. 403–416, 2008.
[56]
J. J. Myers, W. T. Steward, E. Charlebois, K. A. Koester, A. Maiorana, and S. F. Morin, “Written clinic procedures enhance delivery of HIV "prevention with positives" counseling in primary health care settings,” Journal of Acquired Immune Deficiency Syndrome, vol. 37, pp. S95–S100, 2004.
[57]
J. Fehringer, F. I. Bastos, E. Massard, L. Maia, J. H. Pilotto, and D. Kerrigan, “Supporting adherence to highly active antiretroviral therapy and protected sex among people living with HIV/AIDS: The role of patient-provider communication in Rio de Janeiro, Brazil,” AIDS Patient Care and STDs, vol. 20, no. 9, pp. 637–648, 2006.
[58]
C. K. Mbekenga, H. I. Lugina, K. Christensson, and P. Olsson, “Postpartum experiences of first-time fathers in a Tanzanian suburb: a qualitative interview study,” Midwifery, vol. 27, no. 2, pp. 174–180, 2011.
[59]
D. K. Mayer, N. C. Terrin, G. L. Kreps et al., “Cancer survivors information seeking behaviors: a comparison of survivors who do and do not seek information about cancer,” Patient Education and Counseling, vol. 65, no. 3, pp. 342–350, 2007.
