A Quality Improvement Approach in the Partnership for HIV-Free Survival that Responds to Gender Issues

Why address gender issues in the Partnership for HIV-Free Survival

  • Male partners and other family members often influence whether a mother and baby access and remain in care in low- and middle-income countries. It’s important to analyze the social and cultural influences that determine whether a mother accesses and remains in postnatal care, including who makes decisions within families, to be able to respond appropriately.  
  • Engaging male partners or other family members in programs focused on eliminating mother-to-child transmission, such as the Partnership for HIV-Free Survival (PHFS), to educate them about the importance of accessing services, adhering to treatment and remaining in care. This can create champions within families who will support mother-baby pairs to remain in care through the 18-month mark. Family members should only be involved if the female patient is in agreement.
  • Engaging male partners also presents the opportunity to provide services such as HIV testing for males and linking them to treatment to improve their health outcomes. 
  • Collecting and analyzing data on partner and family involvement is an important step to better plan activities that meet the needs of mother-baby pairs and to achieve improved outcomes.

Issues which affect access, retention, and adherence to treatment for mother-baby pairs

  • Stigma against HIV-positive mothers: A cultural belief that women are primarily responsible for spreading HIV can lead to blaming women who test HIV-positive for bringing it into the families. HIV can be associated with perceptions about women engaging with multiple partners, stigmatizing them even more. A belief that women living with HIV should not get pregnant can discourage women from being tested for HIV or following up with antiretroviral drugs.
  • Decision-making power: Male partners or other family members sometimes refuse to allow women to receive services after delivering a baby because they do not want to pay or are afraid they will be stigmatized if their status is disclosed by a female partner receiving services. 
  • Fear of disclosure: Women can fear violence or abandonment if they disclose their HIV-positive status which can lead pregnant women to avoid disclosing their status and accessing treatment.
  • Access and time: Women can be unable to access services due to lack of resources to go to the facility, the facility may be too far away, or due other household responsibilities such as caring for children. Community or religious beliefs or other constraints on women may also make it challenging for them to leave the house during the postnatal period. Other social responsibilities, such as tending to a sick family member or attending a burial, can prevent women from accessing services. 

Questions to help improve outcomes in the PHFS initiative

  • What issues or beliefs within families and/or communities limit the ability of mother-baby pairs to access or remain in HIV care? 
  •  Who makes decisions within families about whether women receive care?
  • How can identified issues be addressed in way that’s patient-centered and allows women to access and remain in care? 
  • What opportunities exist in the community to promote practices that will prevent mother-to-child transmission of HIV?
  • What responsibilities do women have in the household that prevent them from coming to the facility?
  • Do women have resources to pay for transport to the facility when the distance is far?
  • Do women have responsibilities to leave their home town for work? How does this influence the ability of mother-baby pairs to remain in care? 
  • How are men who accompany their female partner and baby to the facility viewed by the community?
  • What issues men have to deal with when they come to the facility? 

Change ideas to respond to identified gender issues

Issue identified

Change idea to test to achieve goal

Mothers-in-law are decision-makers within families and they do not understand the importance of and therefore do not support women accessing HIV services

  • Ask female patients if they want to invite their mothers-in-law to attend a clinic visit and have a health professional provide the mother-in-law with basic information about the importance of remaining in treatment
  • Create a community mobilization campaign targeting mothers-in-law about the health benefits and the importance of mother-baby pairs remaining in treatment

Male partners and mothers-in-law are unable to participate in mother-baby appointments because they are only held during working hours

  • Hold education sessions multiple times, not only during work hours: include night and weekend clinic hours to help accommodate men’s schedules and other obligations to give them a greater chance to participate

HIV-positive women experience stigma in the community and fear disclosing their status, which causes them to not attend clinic sessions

  • Utilize community and religious leaders as gatekeepers to community change: engage community and religious leaders to redefine beliefs in the community and to encourage people to access services

Illustrative indicators to measure progress 

  • % of females who have a male partner attend a clinic visit
  • % of male partners who are tested for HIV at mother-baby visits
  • % of male partners who test positive for HIV and are linked to care
  • % of mothers-in-law who receive targeted information about the importance of HIV care

Do no harm approach

  • Family issues are very sensitive, and it’s important that health services not increase inequalities or cause unintended negative consequences. Involving male partners and other family members, such as mothers-in-law, and educating them about the importance of women remaining in care can be an excellent approach to retain mother-baby pairs. Yet it’s important that family members are only engaged when a woman decides to do so.
  • Forcing female patients to disclose their status to their partners or family members can result in them being subjected to violence.
  • Prioritizing couples in HIV services to increase partner involvement can lead to single women, who may already be more disadvantaged, having to wait extended periods of time. It’s important to have a balanced approach that does not leave single women disadvantaged.
ASSIST publication: 
ASSIST publication
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