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Cracking the code

getting men tested in rural Africa

Schell, Ellen S.; Geoffroy, Elizabeth; Phiri, Mphatso; Bvumbwe, Alice; Weinstein, John; Jere, Joyce M.

doi: 10.1097/QAD.0000000000000913

Global AIDS Interfaith Alliance, San Rafael, California, USA.

Correspondence to Ellen S. Schell, PhD, Global AIDS Interfaith Alliance, 2171 Francisco Blvd East, Suite I, San Rafael, CA 94901, USA. E-mail:;

Received 28 August, 2015

Revised 18 September, 2015

Accepted 29 September, 2015

The emphasis on women in the African AIDS epidemic has left men behind [1]. Although HIV disproportionately affects women in this context [2], they are more likely than men to come into contact with the healthcare system because of child bearing and rearing, and thus more likely to receive early HIV diagnosis and treatment, improving their treatment outcomes. In Malawi, the Option B+ treatment policy has made dramatic gains for pregnant and breastfeeding women and their infants. Men do not have the same contact with and encouragement from the healthcare system; they get into care later and are disproportionately represented among AIDS deaths [3]. The ambitious UNAIDS 90–90–90 targets will not be met without concerted efforts to engage men [4].

Our organization, Global AIDS Interfaith Alliance, provides HIV testing, referral for treatment, and adherence programs through mobile health clinics deployed to remote areas of Southern Malawi [5], where 14.5% of the adult population is HIV positive [6]. A clinical officer, nurse, nurse aide, and a follow-up nurse coordinator responsible for improving linkage to and retention in care staff the four-wheel drive vehicles. Staff travel to remote rural sites designated by the District Health Office and provide HIV and other basic health services, free of charge.

We noticed a wide sex disparity in our HIV testing data; in 2013, only 23% of those coming to our clinics for testing were men. We began to investigate how to address this gap. As a first strategy, staff worked through religious organizations. Two clinic staff contacted their pastors and asked them to preach about the importance of HIV testing and encourage men to attend male-focused HIV testing events on a specific weekend day. Because we suspected that some congregants might be uncomfortable being tested by a fellow church member, staff other than the two clinicians who had approached their pastors conducted the testing day. Results of this first approach were promising; between the two churches, 65 men (and eight of their wives) were tested.

We conducted a formative evaluation of barriers to male testing. The qualitative study interviewed 30 randomly selected village men and found that they did not feel that messages about HIV testing had been targeted to men. Excessive distance to testing locations, inconvenient hours of operation, fear of stigma, and concerns that test results would not be kept confidential were cited as barriers to testing.

To address these concerns, we used community sensitization meetings in places where men gathered to publicize dates when we would be holding male-targeted testing. We held some on Saturdays, when working men could more easily attend. We conducted events at convenient locations where men congregated, including a village football pitch and workplaces such as tea plantations and a construction site. We sought out ‘the places where men hide’, such as markets where they gather to eat and socialize, and encouraged them to take advantage of the testing opportunity. In one village, we learned of a men's empowerment group working to change cultural values around masculinity and offered testing for the members.

Although our testing days were targeted at men, we found that women also came, often seeking couples testing and counseling. Since starting the program in 2014, we have held 28 events and tested 1058 people (61% of them men, more than twice the proportion of men tested at the clinics prior to initiation of the program). Four percent of those tested through the program were HIV positive, possibly suggesting that we are reaching lower risk individuals who otherwise may not go for testing.

Program data collected on participants’ primary reason for coming for testing found ‘convenience of location’ selected by 75%, showing that easy access is a critical driver. When asked who convinced them to be tested, the majority of participants (69%) reported ‘Global AIDS Interfaith Alliance staff’, with ‘myself’ and ‘religious leader’ (both 9%), coming in a distant second and third, suggesting the power of community sensitization provided by our staff.

Our experience demonstrates that men (and couples) can be effectively targeted for HIV testing. Of key importance are community engagement and programmatic flexibility. Implementers need to ensure comprehensive community sensitization, earn the trust of opinion leaders, provide compassionate, sensitive, and confidential care to clients, and promote community ownership of programs. Programmatic flexibility means seizing opportunities for testing as they come, understanding where men gather, and skillfully approaching and educating men on the advantages of knowing their HIV status and the benefits of engaging in care if found HIV positive.

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The authors wish to thank the Elizabeth Taylor AIDS Foundation for their support of the GAIA Elizabeth Taylor mobile health clinics and the District Health Office of Mulanje for its cooperation and assistance.

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Conflicts of interest

Funding for the Global AIDS Interfaith Alliance (GAIA) Mobile Clinics is provided by the Elizabeth Taylor AIDS Foundation. There are no conflicts of interest.

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1. Dovel K, Yeatman S, Watkins S, Poulin M. Men's heightened risk of AIDS-related death: the legacy of gendered HIV testing and treatment strategies. AIDS 2015; 29:1123–1125.
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