Engaging men to positively impact the adherence and retention of HIV-positive women in Malawi

The aim of this original dissertation is to uncover various aspects related to the engagement of men in promoting the adherence and retention of HIV-positive women in Malawi, with the ultimate goals being to design and implement effective intervention. Its originality stems from the novel inclusion of the issue of male engagement, utilising theories and frameworks from global health and social science, with particular attention to gender theories. From a gender perspective, I would say that this thesis aims to realise the potential of engaging men in promoting gender equality in the Sexual and Reproductive Health and Right Service. The main question that drove me during this three-year journey was: How can we design more meaningful interventions and programmes by taking male support into account, given that one cause of drop-out or low adherence is the scarce male partner support received by HIV-positive women? This dissertation consists of two main sections: one theoretical part where I systematically review the literature to understand which interventions have been implemented so far in terms of male partner support in sub-Saharan Africa; the empirical portion conducted in the field includes a quantitative and qualitative study. The quantitative study (Chapter 3) is an observation study that has been designed with my research group where we determined the rate of their partner involvement and its determinants. In the qualitative study (Chapter 4), we conducted focus group discussions and interviews with healthcare workers, expert patients and couples attending the clinic. The aim is to explore the relationships between partners to understand what is meant by male partner support in adherence of HIV positive women, its intersection with gender norms and roles in the household, and finally its implications at policy level. The theoretical part (Chapter 2) identifies a scarce number of interventions aimed at involving men in antenatal clinic and it brings to light that no appropriate indicators exist to measure male involvement; identifies that single-component interventions are less effective than multicomponent interventions within communities and congregations. The quantitative study (Chapter 3) showed a male attendance of 60% and it points out that economic conditions intersected with gender norms and roles play a crucial role in the engagement of men in care. This was confirmed by the qualitative study (Chapter 4). It confirms the previous literature which suggests that male partner support is expressed by providing access to transport to the clinic and accompaniment to appointments and it highlights that support is more complex than previous literature reported, and in some cases is an issue of the male partner granting permission for the woman to access the necessary resources to attend the clinics. This may turn out to be an act of control rather than an act of support over women further reducing their agency and freedom. It may have harmful consequences to be considered during the design of programmes and policies. The conclusion suggests considering to design and implement robust multicomponent interventions within communities and congregations targeting specifically couples and men, and training community healthcare workers and expert patients; to agree on a male involvement indicator that captures gender norms, roles and masculinities; to carefully explore how gender roles and norms in the household shape everyday life and raise awareness of their unintended consequences. To conclude, building interventions aimed at transforming harmful gender norms and roles to improve adherence is the meaningful strategy to adopt to enhance male involvement. This thesis has been possible thanks to the various journeys to Malawi and field works where I tried to go deeper into Malawian culture. This added incredible value to all my findings.