Men's Perceptions of HIV Care Engagement at the Facility- and Provider-Levels: Experiences in Cote d'Ivoire

"Understanding the perspectives of men is critical to tailoring health communication and clinical services to meet the needs of men."

Throughout sub-Saharan Africa, a higher proportion of women than men undergo HIV testing and a higher proportion of women living with HIV have been diagnosed and are on antiretroviral therapy (ART). Prior research suggests that the reasons for the disparity between men and women in seeking HIV services are related to both gender norms and service-related factors. This study explores perceived service-related benefit and cost factors affecting engagement with HIV services among men in Côte d'Ivoire.

A framework cited in the paper describes engagement with the HIV care continuum in low- and middle-income countries (LMICs). It suggests that individuals unconsciously weigh perceived values or benefits associated with care-seeking (e.g., social support or feeling healthy) against perceived costs (e.g., stigmatising treatment or inefficient services). On this model, value/cost factors influencing decision-making operate at each level of the socioecological model: from the individual, interpersonal, facility, and community up to the policy domain. This model also proposes that many of these "decisions" occur unconsciously and are based on cognitive biases described in the field of behavioural economics. Within public health, the benefit and cost language captures the complex conscious and sub-conscious calculations that occur in decision-making about HIV service uptake.

The researchers explored men's perspectives from data collected in autumn 2016 as part of a larger formative qualitative study in 3 urban areas in Côte d'Ivoire (Abidjan, Bouaké, and San Pedro). It involved 28 in-depth interviews (IDIs) conducted with men living with HIV (MLHIV) in treatment (15) and MLHIV not in treatment (13) and 45 IDIs and 28 focus group discussions (FGDs) conducted with men whose HIV status was unknown to investigators.

Overall, the researchers found "both costs and benefits related to interactions with the provider. Costs included the fear of unwanted disclosure, actual or anticipated stigma, and the belief that providers were not administering the HIV test properly. These costs were offset by the perceived benefits of social support from the provider and clinical guidance on the treatment journey. Men also identified a plethora of costs linked to the facility itself, separate from interactions with the provider. The layout of the clinic - where clients living with HIV waited or which provider they saw - was felt to compromise the confidentiality of clients' HIV status. Men also identified wait times, ART stock-outs, and financial costs as barriers. Finally, some men expressed a belief that the formal health system was primarily for women and children, and that clinics were feminine spaces not to be frequented regularly by men." The latter point also illustrates some men's perceptions that seeking help is an admission of weakness, a characteristic inappropriate for men.

The findings highlight what the researchers describe as "a dichotomy between anticipated negative experiences among men not engaged in HIV care in [the] study and [the] lived, generally positive, experiences among men engaged in care." They offer some recommendations to reduce barriers to testing and engagement in care related to service delivery:

• Re-emphasise the critical importance of maintaining confidentiality among service providers.
• Implement communication and community-based interventions that specifically incorporate gender norms and gender roles to reach men and potentially shift perceptions of healthcare facilities.
• Support men's testing and care outside of facilities (in spaces considered more suitable by men overall), such as through community-centred ART delivery and other differentiated models of care.

In conclusion: "This work adds to the growing body of practical knowledge that can be used to improve engagement with HIV services among men in Cote d'Ivoire."