The proposed fellowship will prepare the applicant for a research career focused on HIV policies and their implementation in practice. A comprehensive training plan accompanies the proposed study and has the following objectives: (1) develop knowledge of both HIV policies and the implementation of HIV testing protocols in sub-Saharan Africa (SSA);(2) increase methodological capacity in surveys, in-depth interviews, and policy discourse analysis;and (3) publish and present research findings. The specific focus of the proposed study is to examine men's underutilization of HIV testing, and thus life-prolonging treatment. Men constitute the majority of AIDS-related morbidity and mortality in SSA even though they are less likely than women to be infected. A primary contributor to men's high rate of AIDS-related mortality is their failure to access HIV testing: in Malawi, where the study will be conducted, men comprise only 33% those tested for HIV. A common explanation is that men are more reluctant than women to learn their HIV status due to concerns that a positive status would compromise their masculinity. A plausible additional explanation is structural rather than individual: as a result of feminized policies that emphasize women's excess vulnerability to HIV, healthcare providers offer fewer HIV testing services to men than women. In Malawi, virtually all women seeking antenatal care are tested for HIV, but men must specifically request testing. Yet even in venues where all clients should be offered HIV testing, as is the case for Malawians with TB or sexually transmitted infections (STIs), men are less likely to be tested. A possible explanation could be that feminized HIV policies affect how providers interact with male versus female clients. Although studies in high-income countries show that feminized sexual health policies can lead providers to offer fewer health services to men than women, there are no equivalent studies in the high HIV-prevalence countries of SSA. The proposed study in Malawi will be the first to examine if HIV policy influences providers'perceptions of gender and HIV, and whether this affects providers'implementation of HIV testing protocols for TB and STI clients. The study has three aims: (1) To use policy discourse analysis to examine how men and women are portrayed in HIV policy, using as texts both national policies and provider-training materials;(2) To collect and analyze data from in-depth interviews with healthcare providers to assess whether there are differences in their perceptions of male and female clients;(3) To collect and analyze data from exit surveys with TB and STI clients to test whether providers offer HIV testing differently to male versus female clients. Findings from the three aims will be examined together through mixed methods analysis in order to explore the relationship between HIV policy, provider perceptions, and provider implementation of HIV testing protocols. Findings will have implications for HIV policies and can inform interventions designed to increase men's use of HIV services. The project aligns with the mission and objectives of NIMH by addressing the causes of disparities in HIV service utilization among high-risk groups.
The proposed project has the potential to improve public health by addressing a likely structural barrier to men's use of HIV testing, and thus their access to life-prolonging treatment. By examining the unintended consequences of HIV policy on the implementation HIV testing protocols, the project will inform policy recommendations for increasing men's use of testing, which has implications for both HIV prevention and AIDS treatment. The project will also provide insight into how provider perceptions affect their implementation of policy, information that can inform the development of future provider-training materials.