Confidentiality breaches, stigma and a lack of time are stopping men in Côte d’Ivoire from getting tested and treated for HIV

AVERT

April 2019

Interviews with men in Côte d’Ivoire reveal radical differences in the perceptions of those who do and don’t access care.

Research, published in PLOS ONE, found many of the worries of men out of care are not reflected in the experiences of those with regular contact with services. Men’s perceptions were linked with their level of engagement with HIV care, with men who have regular contact with HIV testing and treatment services displaying more positive attitudes than those with little or no contact with such services.

Côte d’Ivoire introduced a ‘treat all’ approach in 2017, meaning anyone diagnosed with HIV is immediately eligible for treatment regardless of the level of virus in their body. Despite this, just 29% of men living with HIV in the country were on treatment in 2017, compared to 60% of HIV positive women. This reflects the situation across sub-Saharan Africa, with men significantly less likely than women to get tested for HIV, less likely to be in HIV care, and more likely to die of AIDS-related illnesses.

Working in the cities of Abidjan, Bouaké and San Pedro, researchers conducted in-depth interviews and focus group discussions with 227 men aged 25 to 49. Some participants were living with HIV and on treatment, some were HIV positive and not on treatment, and some had unknown HIV status.

Participants were asked to describe benefits and concerns relating to HIV care in regards to both their personal interactions with nurses and physicians and the workings of health facilities.

Men living with HIV who were not on treatment and men with unknown HIV status were more likely to express concern about mistreatment or confidentiality breaches, while men living with HIV who were in care did not generally perceive health providers to display a lack of confidentiality. However, men across the board said the physical layout of health facilities – whereby people living with HIV were grouped together as they waited to be seen – did not adequately protect their privacy.

Another key concern related to actual or anticipated stigma. Men living with HIV who were not in treatment described having negative experiences at health facilities stemming from anticipating or experiencing demeaning treatment from staff due to their HIV status. Some men also expressed the belief that care providers were not administering HIV tests properly, with men who had not tested for HIV particularly sceptical of the ability of health workers to accurately carry out HIV tests. Conversely, men living with HIV who were in treatment tended to be positive about their interactions with care providers and did not cite stigma as an issue.

A number of HIV positive men, whether they were engaged in care or not, described interactions with staff as beneficial, particularly around the time of diagnosis.

Newly diagnosed men spoke of feeling encouraged when care providers gave them examples of other people living with HIV who appeared to be healthy. Men also described being supported to disclose their status to partners and receiving regular, supportive phone calls between appointments as helping them to accept their HIV status. The way in which some care providers ‘normalised’ HIV by comparing it to other common and less stigmatised illnesses also resonated with a number of men.

In general, men living with HIV who were in care viewed and valued providers as the primary source of guidance for maintaining their health. Similarly, men who had not tested for HIV said that they would be motivated to attend a health facility to receive clinical guidance should they be diagnosed as HIV positive. However, a number of men living with HIV criticised healthcare staff for using too many technical terms or not taking time to explain treatment. ART eligibility, viral load, and CD4 count were all concepts that many participants, regardless of their HIV status, were unable to explain.

Some men expressed a belief that the formal health system was primarily for women and children, while viewing the traditional care or self-medicating with herbal products as sometimes more suited for their own care. This view was also partly explained by some men’s perceptions that seeking help was an admission of weakness. These attitudes were more common among men who had not tested for HIV than men living with HIV, suggesting more must be done to reach out to men who shun healthcare as a result of harmful gender norms.

The practical issue of not having enough time to wait for a delayed appointment also discouraged some men from accessing HIV testing and care. Missing work to attend clinic visits was also described by men across the board as a major concern, with many saying this stopped them from seeking testing and/or treatment. Men living with HIV also mentioned the potential or actual cost of missing work due to the side effects of medication as a barrier to starting or staying on treatment. ART stock-outs were also cited as a reason for interrupting treatment.

Men of unknown HIV status particularly perceived visits to the health facility as expensive due to potential fees, even though HIV services in Côte d’Ivoire are generally delivered for free. When discussing financial costs, traditional care was frequently cited as an alternative and often preferred source of healthcare. Distance, convenience, and familiarity also meant men living with HIV who were not in treatment were more likely to access traditional care, regardless of whether they felt it was more effective or not. Conversely, men living with HIV who were on ART tended to critique the use of traditional medicine.

This research adds to the growing body of practical knowledge that can be used to better tailor HIV testing and treatment for men in Cote d’Ivoire. In general, understanding male perspectives on HIV care must be better prioritised or millions of men will continue to miss out on life-saving treatment with knock on effects for HIV transmissio

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